i 











Glass 

Book T~7 IJ&5 



THE 
PREVENTION OF TUBERCULOSIS 



THE PREVENTION 
OF TUBERCULOSIS 



BY 

ARTHUR NEWSHOLME, 

M.D., F.R.C.P. 

PRESIDENT OF THE EPIDEMIOLOGICAL SECTION OF THE ROYAL SOCIETY OF MEDICINE 
LATE MEDICAL OFFICER OF HEALTH OF BRIGHTON 



WITH THIRTY-NINE DIAGRAMS 



NEW YORK 
E. P. DUTTON AND COMPANY 

31 WEST TWENTY-THIRD STREET 
1908 



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PREFACE 

THE promise to write this book as one of a series dealing 
with the public aspects of Medicine was made in 1906. 
The greater part of it was written over a year ago, 
Part I. almost entirely so, the quotations from the Second 
Interim Report of the Royal Commission appointed to inquire 
into the Relations of Human and Animal Tuberculosis, with 
such slight modifications of inference as were necessitated by 
it, being added subsequently. 

Part II. is a restatement of an investigation of which the 
results were last set forth in the Journal of Hygiene for July 1906. 
Although necessarily lengthy and full of detail, the argument 
and conclusion that institutional segregation is the predominant 
cause of the decline of phthisis in this country has great import- 
ance in its bearing on the administrative measures considered 
in Part III. It is perhaps unfortunate that the argument is 
continuous from end to end, and that its effect is misconceived 
when only parts of it are considered disjoined from the remainder. 
In the absence of this continuity the investigation could have 
yielded no more than ground for surmise or conjecture. The 
history of the public health service gives familiar proof of the 
important place taken by scientific hypothesis among the tools 
at our disposal. When, however, conclusions can be tested 
by actual experience, such experience obviously affords a surer 
basis for administrative action ; and in a matter of such 
immense importance to public health as the control of tuber- 
culosis, the intricacies of a statistical inquiry embodying historical 
and international experience are worth undertaking and master- 
ing if, as happens often and is certainly so in the present case, 
the question cannot be discussed conclusively without it. 

The chapters on statistics are indispensable to the main 
arguments of the book, especially to those in Part II. If, for 
instance, statistics of phthisis are largely vitiated by trans- 
b v . 



vi THE PREVENTION OF TUBERCULOSIS 

ference between this disease and bronchitis, important reasoning 
as to the course of phthisis can scarcely be based on them. 
Where not otherwise stated, the English statistics are derived 
from the Reports of the Registrar-General of Births and Deaths 
and from Dr. Tatham's letters therein ; some of these tables 
have been calculated separately, or readjusted for my special 
purposes. 

The bibliography on p. 415 does not pretend to be complete. 
It comprises only the papers and books actually quoted in this 
volume. It is hoped that the index of names of places and 
persons will form a useful supplement to the subject-index. 

This volume is written almost solely from the standpoint 
of the public health administrator, and is intended primarily 
for medical officers of health. It is believed, however, that it 
will also be interesting and useful to all medical practitioners, 
to many members of Sanitary Authorities and Hospital Com- 
mittees, to patients themselves, and to that increasing proportion 
of the public who desire to know more of preventive medicine. 
As therapeutics in the more limited sense of the word has been 
entirely excluded from its scope, there appears to be no impedi- 
ment, except, perhaps, lack of interest, to this wider utility of 
the discussion of tuberculosis here attempted. 

I have to thank my friend H. C. Lecky, M.A., M.B., and H. P. 
Newsholme, B.A., B.Sc, for reading portions of the manuscript, 
and for valuable suggestions, and the latter for seeing the 
volume through the press. 

A. N. 



LIST OF FIGURES 

FIG. PAGB 

i . Comparative Magnitude of some of the Chief Preventable Causes 

of Death in England and Wales . 5 

2. England and Wales, 1904. — Male and Female Death-rates from 

Phthisis at different Age-periods . . . 9 

3. Deaths from Phthisis at each Age-period per 100 Deaths from the 

same Disease at all Ages . . . . .10 

4. Deaths from Phthisis at each Age-period per 100 Deaths from all 

Causes at the same Age-period . . . .11 

5. Relative Death-rates from (a) Phthisis, (b) Bronchitis and Pneu- 

monia in England and Wales, the rates for 1901-04=100 . 25 

6. Comparison between 1861-70 and 1901 of relative Death-rates at 

different Age-periods from Bronchitis plus Pneumonia and 
from Phthisis . . . . . . .28 

7. Relative Death-rates from different Tuberculous Diseases from 

1850-54 to 1901-04, the Death-rate in the most recent period in 

each instance being stated as 100 . . . • 34 

k 8. Section of a Lung chiefly in the first stage of Phthisis . . 46 

9. Section of a Lung chiefly in the second stage of Phthisis . . 46 

v io. Section of a Lung chiefly in the third stage of Phthisis . . 46 

11. Section of a Lung exhibiting Cretaceous Masses . . .46 

12. Acinus of the Lung, enlarged ten times . . . .111 

13. Death-rates from Phthisis for Males and Females at different Age- 

periods in England and Wales, Sheffield, and Birmingham . 166 

14. Female Death-rate from Phthisis at each Age-period in 1861-70, 

and in 1 891 -1900, that of Males at the same Age-period = 100 . 170 

15. Male Death-rate from Phthisis at each Age-period in Urban and 

Rural Counties . . . . . ..173 

16. Female Death-rate from Phthisis at each Age-period in Urban 

and Rural Counties . . . . . . 174 

17. Death-rate from Phthisis in Males and Females at each Age-period 

in Urban Counties . . . . . . 175 

18. Death-rate from Phthisis in Males and Females at each Age- 

period in Rural Counties . . . . .176 

19. Showing steady improvement in Housing Conditions in Ireland . 227 

20. Proportional Phthisis Death-rates and Wheat Prices in the U.K. 233 

21. Proportional Phthisis Death-rates and Wheat Prices in Paris . 234 

22. Proportional Tuberculosis Death-rates and Wheat Prices in 

Prussia. ....... 234 

vii 



viii THE PREVENTION OF TUBERCULOSIS 

FIG. PAGu 

23. Proportional Phthisis Death-rates and Wheat Prices in Mass., 

U.S.A. ........ 235 

24. Proportional Phthisis Death-rates and Cost of Food in the U. K. . 237 

25. Proportional Tuberculosis Death-rates and Cost of Food in Prussia 237 

26. Proportional Phthisis Death-rates and Cost of Living in England 239 

27. Relative Changes in Pauperism and Phthisis Death-rate in 

England ... . . . . .245 

28. Relative Changes in Pauperism and Phthisis Death-rate in 

London . . . . . . . 246 

29. Relative Changes in Pauperism and Phthisis Death-rate in 

Scotland ....... 247 

30. Relative Changes in Pauperism and Phthisis Death-rate in 

Ireland . ...... 248 

31. Comparison of the Changes in the Death-rates from Typhus and 

from Phthisis in Ireland and in England and Wales . 260, 261 

32. Number of Total Lepers and of Lepers in Asylums in Norway . 264 
23. Rates of Changes in Phthisis Death-rates and in the ratio of 

Institutional to Total Deaths in England . . .271 

34. Rates of Changes in Phthisis Death-rates and in the ratio of 

Institutional to Total Deaths in London . . . 272 

35. Rates of Changes in Phthisis Death-rates and in the ratio of 

Total to Indoor Pauperism in England . . . .278 

36. Rates of Changes in Phthisis Death-rates and in the ratio of 

Total to Indoor Pauperism in Scotland . . . 279 

37. Brighton. Annual Notifications, Sputa examined, and Admissions 

to the Sanatorium . . . . . • 34 1 

38. Comparison of Death-rate from Phthisis and other forms of 

Tuberculosis at different Age-periods . . . .361 

39. Block Plan of Isolation Hospital . . . . -397 



CONTENTS 

PART I 
CAUSATION OF TUBERCULOSIS 

CHAP. PAGE 

I. Magnitude of the Evil : A. Mortality . . 3 

II. Do. B. Sickness and Economics 13 

III. Are the Statistics relating to Tuberculosis Trust- 

worthy ? ...... 22 

IV. The History of Phthisis . . . • 35 
V. The Morbid Anatomy and Symptoms of Phthisis . 43 

VI. The Tubercle Bacillus . . . . 51 

VII. Infectivity of Tuberculosis : A History of Views 

held . . . . . . • 55 

VIII. Infectivity of Tuberculosis: B. Experimental 

Evidence . . . . . • 59 

IX. Infectivity of Tuberculosis: C. Statistical and 

Clinical Evidence . . . . .62 

X. Latency in Tuberculosis . . . -74 

XI. Sources of Infection: Minor Sources . . 86 

XII. Do. : Dust and Spray . . 89 

XIII. Circumstances limiting the Amount of Infection by 

Dust and Spray . . . . .101 

XIV. The Portals of Infection : A. Infection by Inhala- 

tion ....... 106 

XV. The Portals of Infection : B. Infection by Ingestion 115 
XVI. Relation of Bovine and Human Tuberculosis . 121 

XVII. Evidence of the Occurrence of Bovine Tuberculosis 

in Man . . . . . 131 

XVIII. Tuberculosis from Meat and from Milk and other 

Dairy Products . . . . . 139 

XIX. Domestic Infection . . . . .146 

XX. Infection in Attendance on the Sick . .152 

XXI. Industrial Infection . . . . . 157 

XXII. Personal Influences other than Infection favour- 
ing Tuberculosis : Susceptibility to Infection . 161 

XXIII. Age and Sex . . . . . .164 

XXIV. Personal Conditions lowering Resistance to In- 

fection ...... 177 

XXV. Hereditary Disposition to Phthisis . . .182 



x THE PREVENTION OF TUBERCULOSIS 

CHAP. PAGE 

XXVI. Conditions of Environment lowering Resistance 
to Infection, Social Misery, and Insanitary 
Circumstances . . . . .191 

XXVII. Climate and Soil . . . . .194 

PART II 

THE MEANS BY WHICH THE REDUCTION OF 
MORTALITY FROM TUBERCULOSIS ALREADY 
OBTAINED HAS BEEN SECURED 

XXVIII. Introductory ...... 205 

XXIX. Tuberculosis and General Health in Various 
Communities : Virulence, Natural Selection, and 
Decadence . . . . .210 

XXX. Tuberculosis in Urban and in Rural Communities . 220 
XXXI. Tuberculosis in Overcrowded Communities . 224 

XXXII. Tuberculosis in Communities of Varying Well- 
being ... . . . . 230 

XXXIII. Tuberculosis in Communities of Varying Sanitary 

Education and Sanatorium Provision . -252 

XXXIV. The General Relations of Tuberculosis and other 

Chronic Infectious Diseases to Institutional 
Segregation ...... 256 

XXXV. Tuberculosis in Communities with Varying 

Amounts of Institutional Segregation . . 266 

XXXVI. The Relative Influence of Institutional Segrega- 
tion AND OF OTHER MEASURES FOR THE CONTROL 

of Tuberculosis ..... 292 

PART III 

MEASURES FOR THE REDUCTION AND ANNIHILA- 
TION OF TUBERCULOSIS 

XXXVII. General Scheme of Preventive Measures . .301 

XXXVIII. The Early Recognition of Phthisis in relation 

to Prevention . . . . . 306 

XXXIX. The Medical Practitioner in relation to Preven- 
tive Measures . . . . .316 
XL. The Consumptive Patient in relation to Preven- 
tive Measures . . . . 324 
XLI. The Prevention of Indiscriminate Expectoration 331 
XLH. The Notification of Phthisis . . . 338 
XLIII. The Sanitary Authority in relation to Preventive 

Measures against Tuberculosis . . . 351 

XLIV. Education Authorities and the Prevention of 

Tuberculosis . . . -359 



CONTENTS xi 

CHAP. PAGE 

XLV. The Board of Guardians and the Prevention 

of Tuberculosis ..... 366 

XLVI. Insurance and Friendly Societies in relation 

to the Prevention of Tuberculosis . . 372 

XLVII. Dispensaries and the Prevention of Tuber- 
culosis ...... 2>77 

XLVIII. The RSle of Sanatoria in the Treatment and 

Prevention of Phthisis • . 382 

XLIX. The Institutional Treatment of Phthisis from the 

Public Health Standpoint . . . 394 

L. The Prevention of Tuberculosis arising from 

Food ....... 403 

LI. The Co-ordination of Administrative Measures 

against Tuberculosis . . . .411 

BIBLIOGRAPHY 415 

INDEX OF NAMES OF PLACES . . .423 

INDEX OF NAMES OF PERSONS . . .424 

INDEX OF SUBJECTS .... 427 



PART I 
CAUSATION OF TUBERCULOSIS 



TERMS EMPLOYED 

Tuberculosis: the general name given to the disease result- 
ing from the invasion of any part of the body by the tubercle 
bacillus. 



General Tuberculosis . 
Acute Miliary Tuberculosis 
Acute Tuberculosis 
Phthisis 

Pulmonary Phthisis 
Pulmonary Tuberculosis 
Consumption 

Tabes Mesenterica 
Tuberculous Peritonitis 

Tuberculous Meningitis 
iVcute Hydrocephalus 
Brain Fever (in part) 
Lupus . 
Caries . 
Scrofula 



\ Names given to tuberculosis where 
J- many parts of the body are 
J attacked simultaneously. 

Tuberculosis of the lungs. 



Tuberculosis of the peritoneum 
- and of the abdominal lym- 
phatic glands. 

Tuberculosis of the membranes 
surrounding the brain. 

Tuberculosis of the skin, 
bone, 
lymphatic 



glands. 



7 Consumption, Tabes (both of Latin origin), and Phthisis (of 
Greek origin) are all words the literal meaning of which is 
"wasting." 

The term Phthisis has been used sometimes in a sense wider 
than that of Tuberculous Phthisis or Pulmonary Tuberculosis, 
e.g. miners' phthisis, knife-grinders' phthisis, etc. In most, if 
not in all such diseases, tuberculosis forms an important, though 
possibly superadded, cause of death. Possibility of error from 
this cause will only affect the statistics of special localities. 



CHAPTER I 
MAGNITUDE OF THE EVIL: A. MORTALITY 

TUBERCULOSIS is a disease caused by the destructive 
lesions set up in the lungs or in other parts of the body 
by a special bacillus or microbe. The disease is infectious, 
i.e. is communicable from man to man and from animals to 
man ; and it never originates in the body apart from the invasion 
of the special bacillus. 

Being an infective disease, tuberculosis comes into the same 
category as the infectious diseases enumerated in Tables I. and 
III. Large sums of money very properly are spent each year 
in the prevention of these diseases ; hitherto but little has of 
set purpose been spent on measures for the prevention of tuber- 
culosis. We may, therefore, with advantage consider, in the 
first place, the relative magnitude of these different causes of 
death. In Table I. are set out the deaths from the acute infectious 
diseases and from tuberculosis. 



Table I. 1 — England and Wales, 1904 

Number of Deaths from — 

Measles and German Measles 

Whooping-Cough 

Diarrhoea and Dysentery 

Enteric Fever 

Diphtheria 

Scarlet Fever 

Typhus Fever 

Small-pox 



Pulmonary Phthisis 

All other Tuberculous Diseases 



12,341 

11,909 

29,674 

3,153 

5,763 

3,77o 

37 

5o7 

67,154 

41,851 
1 8,354 

60,205 
Thus tuberculous diseases in 1904 caused 60 deaths for every 



1 All the statistical material relating to England and Wales contained in 
this volume is derived from Dr. Tatham's valuable annual letters to the Registrar- 
General of Births and Deaths, unless otherwise stated. 

3 



4 THE PREVENTION OF TUBERCULOSIS 

67 caused by the aggregate of the chief acute infectious diseases. 
These figures do not bring out fully the relative importance 
and seriousness of deaths from tuberculosis. Although infantile 
deaths are regrettable, they do not cause so great a loss to the 
community and so much distress and suffering to the survivors 
in a bereaved family as do deaths in early and middle life. The 
following table is important in this connection : — 

Table II. — England and Wales, 1904 

Out of every 100 Deaths at all Ages the number occurring at different 

Ages from each Cause of Death was — 





Under 10. j 10-20. 

i 


20-45. 


1 
45 _ 6S. j 65 and over. 

I 


Measles .... 

Whooping-Cough . 

Diarrhoea 

Phthisis .... 


99-1 

99 '9 

93 "5 

4-8 


O'l 

0*2 

IO"I 


0-3 
07 

56-5 


1 

o-i 

... 1 

i-6 4-0 
25"3 3'3 



Thus 99 out of every 100 total deaths from measles and whooping- 
cough, and 94 out of every 100 deaths from diarrhoea, occurred 
under 10 years of age, while only 5 out of 100 deaths from 
pulmonary tuberculosis occurred under this age ; and during 
the working years of life (20-65) 82 occurred out of every 100 
total deaths from phthisis, as against no deaths from whooping- 
cough, less than a half per cent, of the total deaths from measles, 
and less than 2-§- per cent, of the total deaths from diarrhoea. 

If we compare the mortality from tuberculosis with that 
from infective diseases, other than those enumerated in Table I., 
we have the following result : — 

Table III. — England and Wales, 1904 
Number of Deaths fr oi?i — 



Influenza . 


5,694 (the highest number in any 




was 13,756, in 1890). 


Puerperal Fever . 


1,654 


Erysipelas .... 


1,206 


Syphilis and other Venereal Diseases 


1,871 (doubtless understated). 


Tetanus (Lock-jaw) 


257 


Malaria .... 


106 


Anthrax .... 


20 


Glanders .... 


4 


Hydrophobia 


(in 1885 the number was 60 




not been so high since). 




10,812 



it has 



All forms of Tuberculosis 



60,205 



MAGNITUDE OF THE EVIL 5 

Evidently none of these diseases occupies so important a place 
as tuberculosis, though in the public administration of the 




Fig. i. — Comparative Magnitude of some of the Chief Preventable Causes of 
Death in England^and Wales 



6 THE PREVENTION OF TUBERCULOSIS 

country much larger sums are spent in the control of hydro- 
phobia, glanders, anthrax, and puerperal fever than have hitherto 
been spent in direct measures against tuberculosis. 

In the Registrar-General's returns for England and Wales other 
diseases than those enumerated above are classified as infective, 
i.e. produced byjinfection received from without. Omitting pneu- 
monia for separate consideration, the number of deaths returned 
as due to infective diseases in 1904 was 140,431, the total number 
of deaths from all causes in the same year being 547,784. Of 
the total (140,431), 60,205 were caused by tuberculosis, 77,966 
by the other infective diseases named in Tables I. and III. 
Rheumatic fever, which is undoubtedly infective, though not 
classified as such in the official returns, caused 1788 deaths in 
1904. Probably most, if not all the diseases of the respiratory 
organs have an infective origin, and many not recognised as 
such are tuberculous. Pneumonia in 1904 caused 43,372 deaths, 
bronchitis 42,188, all other diseases of the respiratory organs 
excepting pulmonary tuberculosis 8059 deaths. The relative 
magnitude of the most important preventable causes of death 
is shown in Fig. 1. The list is not complete, but the most 
important items are included. Pneumonia and bronchitis have 
been added, although only partially preventable under present 
conditions. Cancer has also been added, because, although 
not directly preventable, many of the deaths from it are pre- 



Table IV. — England and Wales, 1904 
Death-rate from Phthisis per 100,000 living at each Age-group 



Ages. 


Males. 


Females. 


Persons of 
Both Sexes. 


0- 


39 


31 


35 


5- ■ 








15 


20 


17 


10- 








19 


44 


32 


15- 








80 


102 


9i 


20- 








161 


I2 S 
158 


142 


25- 








213 


184 


35- 








270 


170 


218 


45- 








310 


148 


226 


55- 








255 


117 


182 


65- . . . 


126 


65 


92 


All Ag 


es 






146 


103 


124 



MAGNITUDE OF THE EVIL 7 

veritable by early recognition and removal of the diseased 
parts. 

Mortality in Terms of the PopuLxVtion — Death-rates. — 
In 1904 the death-rate in England and Wales from phthisis 
was 1*46 per 1000 of population among males and 1*03 per 1000 
among females. The death-rate varies greatly at different 
ages, as will be seen from the table on preceding page, derived 
from Dr. Tatham's Report to the Registrar-General. In this 
table the death-rates are stated per 100,000 living at each 
age-period separately for the two sexes. 

The facts in this table can be more clearly seen when set 
out graphically as in Fig. 2. 

The significance of the different age distribution of the 
phthisis death-rate in the two sexes will be subsequently con- 
sidered (p. 168). At present we need only record the fact, 
as bearing on the value of the lives sacrificed to this disease. 
The age distribution of deaths from phthisis may be stated in 
three different ways : — 

(1) The death-rate from this disease may be given per 1000 
or per 100,000 living at each period of life, as in Fig. 2. 

(2) The deaths from this disease may be stated in proportion 
to the total deaths from the same disease at all ages. 

(3) Or these deaths may be stated in proportion to the total 
deaths from all causes at the same age-period. 

The first is the only method which can be employed in com- 
paring the age incidence of the disease in different populations. 
The second and third methods are useful for special purposes. 
By means of the second method we can ascertain the proportional 
incidence of deaths from phthisis at different ages, and by the 
third we can state its importance in proportion to other causes 
of death at each age-period. From these standpoints the second 
and third methods tell us more than the first ; for a high death- 
rate may occur among a relatively small population. Thus 
the male death-rate from phthisis of 126 per 100,000 at ages 
over 65 is higher than that of 39 per 100,000 in male children 
under 5, but the two rates represent an equal percentage 
(3*1) of the total male mortality from this disease at all ages. 
In the following table the second and third ratios mentioned 
above are given for each sex : — 



THE PREVENTION OF TUBERCULOSIS 



Table V. — England and Wales, 1904 
Proportional Mortality from Phthisis 







Males. 


Females. 


Age. 


(1) In propor- 
tion to IOO 
Deaths from 

Phthisis at all 


(2) In propor- 
tion to 100 
Deaths from all 
Causes in the 


(1) In propor- 
tion to 100 
Deaths from 

Phthisis at all 


(2) In propor- 
tion to 100 
Deaths from all 
Causes in the 




Ages. 


same Age- 


Ages. 


same Age- 




period. 


period. 


0- . 


3'i 


07 


3*4 


07 


5- • 




11 


4 '2 


2*0 


57 


10- . 




1 '4 


9'5 


4*3 


20 "6 


15- • 




5'6 


26*1 


97 


35"4 


20- . 




io-8 


38-5 


ii'9 


367 


25- • 




23-1 


37 -o 


25'3 


32'3 


35- • 




22'8 


28-1 


20-3 


21'2 


45- • 




i8- 9 


18 '2 


13-0 


1 1 '2 


55- • 




IO'I 


77 


6-9 


4*4 


65 and upwards . 


3*i 


1 '4 


3 "2 


o-8 


All Ages 




IOO'O 


8-5 


100 *o 


6-o 



The same facts are set forth graphically in Figs. 3 and 4. 
Comparing the three sets of facts depicted in Figs. 2-4, it 
will be noted that the highest male death-rate from phthisis 
occurs at the age-period 45-55, the age-periods 35-45 and 55-65 
coming next. The highest proportion of the total male deaths 
from phthisis occurs at the ages 25-35 an d 35~45 ; and phthisis 
bears the highest proportion to deaths from all causes at the 
ages 20-25 and 25-35. 

In the female sex the highest death-rate from phthisis occurs 
at the ages 35-45, 25-35 coming next, the highest proportion 
to deaths from phthisis at all ages occurs at the ages 25-35, 
and to deaths from all causes at the corresponding age-period 
at ages 20-25. 

Of the total deaths from phthisis 91*3 per cent, in males 
and 87*1 per cent, in females occur at the ages 15-65, the working 
years of life. 

Tuberculous Diseases other than Phthisis. — Phthisis is 
not the only fatal disease due to tuberculous infection. In 1904 































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UHDU 

5 

YEARl 


' 5- 
-10 


10- 15 
-15 -2 


- 20- 
-25 


25-35 


35-45 


45-55 


55-65 

UP 


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WARDS 



Fig. 2. — England and Wales, 1904. — Male and Female Death-rates 

from Phthisis at different Age-periods 

(Males — continuous line ; females — interrupted line) 



10 



THE PREVENTION OF TUBERCULOSIS 























































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iRDS 



Fig. 3. — Deaths from Phthisis at each Age-period per 100 Total 

Deaths from the same Disease at all Ages 

(Males— continuous line; females — interrupted line) 



MAGNITUDE OF THE EVIL 



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Fig. 4. — Deaths from Phthisis at each Age-period per 100 Deaths from all 
Causes at the same Age-period 



12 



THE PREVENTION OF TUBERCULOSIS 



the number of deaths caused by each form of tuberculosis was 
returned as follows : — 



Table VI. — England and Wales, 1904 
Number of Deaths caused by various forms of Tuberculosis 





Males. 


Females. 


Total. 


Pulmonary Phthisis 
Tuberculous Meningitis 
Tuberculous Peritonitis\ 
Tabes Mesenterica J 
Lupus 

Tubercle of other Organs 
General Tuberculosis . 
Scrofula 








23,850 

3,359 

i,994 

1,064 

28 

957 

2,253 

47 


18,001 
3,030 
1,921 

834 
38 

705 

2,062 

62 


41,851 
6,389 
3,915 
1,898 
66 
1,662 

4,315 
109 










33,552 


26,653 


60,205 



The death-rate in 1904 from all the tuberculous diseases ex- 
cluding phthisis was 54 per 100,000 persons, 59 per 100,000 males, 
and 50 per 100,000 females ; the corresponding figures for all 
tuberculous diseases being 178, 205, and 153. Thus phthisis 
accounts for 69*5 per cent, of the total deaths ascribed to tuber- 
culosis. 

The age distribution of the deaths from tuberculous diseases 
other than pulmonary tuberculosis enumerated in Table VI. 
will be more conveniently discussed in the chapter on Accuracy 
of Certification. 



CHAPTER II 

MAGNITUDE OF THE EVIL: B. SICKNESS AND 
ECONOMICS 

IT has been shown in Chapter I. that II per cent, of the 
total deaths in England and Wales are registered as due 
to tuberculosis, and that seven-tenths of these are caused 
by phthisis. Table V. also shows that among males 91 per 
cent, and among females 8y per cent, of these deaths occur 
between the ages 15 and 65, and 86 and yy per cent, in the two 
sexes respectively at ages 20-65. 

Economic Value of Lives Lost. — Each child during his 
years of helplessness and until he is able to support himself by 
his own exertions is having expended upon him time, money, 
and effort, which may be regarded as so much capital invested 
with a prospect of future returns. If he dies in infancy, the 
measurable loss is much less than if death is postponed until 
the age of 15. Although it is scarcely necessary to make 
elaborate calculations as to the expenditure on maintenance, 
etc., which is lost by death occurring before or during school- 
life, it obviously represents a considerable capital sum. Between 
the ages of 15 and 20 it is probably exceptional for the earnings 
to more than balance personal expenditure, and, if this be so, 
all deaths up to the age of 20 may be regarded as involving a 
serious loss of capital expenditure. After this age the problem 
becomes more complicated. During the next five years a large 
proportion of the population marry, and thus incur new obliga- 
tions before the balance against them can possibly have been 
paid off. It is during the ages from 25-65, and especially during 
the ages 25-55, that the worker can hope to pay back the value 
of his own earlier maintenance (a) by personal savings, (b) by 
investing capital in the formation of a home and the upbringing 
of a family in his turn. Each family represents in this respect 
an investment on the instalment system, and the only hope of 



14 



THE PREVENTION OF TUBERCULOSIS 



completing the investment, and leaving no debt for survivors 
to redeem or owe to the community, is for the worker to live 
and to remain able to work, until all his children are able to 
earn their livelihood, and until his wife and himself can maintain 
themselves in their old age. That is the ideal. It can only be 
realised when the worker is not cut down by illness or killed 
by disease or accident. Hence the immense economic significance 
of the fact that among men nine out of every ten deaths from 
phthisis occur between the ages of 15 and 65. Some data for 
the determination of this loss have been calculated by Dr. T. E. 
Hayward (1904) . 1 

Effect on the Duration of Life of the Elimination of 
Phthisis. — Dr. Hayward calculated by the life-table method 
what would be the effect of totally abolishing phthisis from 
the death-returns of England and Wales for the decade 1891- 
1900. The main results thus obtained are summarised in the 
following table : — 

Table VII. — England and Wales, 1891-1900 
Survivors and Future Expectation of Life at Different Ages in Males 





Number of Survivors at 


Future Expectation of 






each Age out of 


Life (Mean After 


Percentage 




100,000 born. 


Lifetime). 


Increase 

in the 

Expectation 










Age. 




Based on the 




Based on the 


of Life 




Based on the 


Mortality 


Based on the 


Mortality 


produced 




Mortality 


from all 


Mortality 


from all 


by the 




from all 


Causes 


from all 


Causes 


Elimination 




Causes. 


excluding 
Phthisis. 


Causes. 


except 
Phthisis. 


of Phthisis. 


0- . 


100,000 


100,000 


44*1 


46*3 


5*o 


5- 






75>°93 


75,256 


53*4 


56-2 


5*3 


iS- 






72,592 


72,897 


45'i 


47*9 


6'3 


25- 






69,446 


70,654 


36-9 


39*2 


6*3 


35- 






64,716 


67,676 


29*2 


30-8 


5*3 


45- 






57,655 


62,138 


222 


23-0 


3 '9 


55- 






47,424 


52,742 


15-8 


l6'2 


2-3 


65- 






33,163 


37,830 


10-3 


10-4 


I'O 


75- 






15,813 


18,303 


61 


6-2 




85- 






3,121 


3,629 









1 It is convenient to note here that when a date is given in brackets after a 
name, the full title of the paper or book quoted will be found in the bibliography 
at the end of this volume. The same remark applies when a name and a page 
reference are given in brackets. 



MAGNITUDE OF THE EVIL 15 

It will be observed that the number of survivors from infancy 
to the age of 15 out of a given number born is not materially 
increased by the elimination of phthisis. From this point 
onwards the elimination of this disease would steadily increase 
the number of survivors. At the age of 55, for instance, the 
number of survivors would be 11 per cent, greater than under 
the actual conditions holding good in 1891-1900, while the mean 
expectation of life would be increased by 2 "3 per cent. 

Financial Gain by the Abolition of Phthisis in Men. — 
Some conception of the financial gain that would be secured 
were pulmonary tuberculosis abolished is given by Table VII., 
which shows that, judging by the experience of 1891-1900 in 
England and Wales, the abolition of phthisis would increase the 
expectation of life of every male aged 15 years by 2*8 years, and 
of every male aged 25 years by 2*3 years. Taking the average 
increase of expectation for the 3,080,166 males aged 15-25 at the 
last census (1901) to be 2*5 years, it follows that these males 
who, in 1901, were at or near the beginning of their working 
life would, but for phthisis, live in the aggregate 7,700,315 years 
more than under present conditions they can expect to do. A 
reference to Table VII. shows that the greatest part of this 
increase of life would be in the working years of life before 65 ; 
and if we assume that the average wage of each is 20s. a week, 
a possible gain of over £400,000,000 might be obtained on the 
above lives, or not far from ten millions sterling annually. And 
this makes no allowance for the loss sustained by protracted 
sickness ; nor for the further loss from premature death of 
women from the same cause. 

Illustrations of Financial Loss by Phthisis. — (1) The 
experience of Friendly Societies throws light on this point. 
Mr. A. W. Watson (1902) has published an investigation of the 
experience of 819,716 members of the Oddfellows Society during 
the years 1893-97. These members represented persons exposed 
in the aggregate for 2,995,724 years to risk of sickness, and for 
3,180,378 years to risk of death. During these years the average 
annual death-rate per 1000 members was 12*3. This Society 
has not published any results as to causes of mortality, but 
the Ancient Order of Foresters has published (1903) a report 
summarising for the five years 1897-1901 the number of total 
deaths and deaths from consumption which occurred among its 



i6 



THE PREVENTION OF TUBERCULOSIS 



580,405 benefit members, equivalent to 2,721,822 years of life. 
The following table summarises the results for them and for 
224,374 wives and widows of members during the same period : — 

Table VIII. — Foresters 
Death-rates from all Causes and from Consumption^ 189 7-1 901 





Benefit Members. 


Wives and Widows of Members. 


Death-rate per 1000 from — 


Death-rate per iooo from — 


All Causes. 


Consumption. 


All Causes. 


Consumption. 


England 
Ireland . 
Scotland 
Wales . 

United Kingdom . 


13-2 

I2'I 

9'6 
127 


1-8 
27 

2'6 

i-8 


I2'I 
I2'0 
IO'I 
I2'8 


i'5 
3"3 
1-8 
17 


12*9 


1-9 


n-9 


i'5 



It is evident that the experience of the Foresters and the 
Oddfellows as regards general death-rates is very similar, and 
it may be assumed that this is so also for consumption, and that 
in both Societies this disease causes at least 15 per cent., or 
about one-seventh of the deaths from all causes. Returning 
for a moment to Table V. and Fig. 4, it will be noted that the 
proportion of deaths from phthisis to total deaths from all 
causes is greatest from 20 to 45 years of age, at which ages 
it varies from a third to a fourth of the total number. At ages 
55-65 it has declined to one-twelfth of the total deaths from all 
causes. In the total experience of the Foresters the proportion 
is, as we have seen, one-seventh, and the proportion must be 
higher than this in the working years of life 15-65. Further 
allowance has to be made for the fact that consumption only 
causes death after prolonged disablement, and almost certainly 
causes a higher proportion of the total sickness than of the total 
mortality. Assuming that it causes one-fifth of the total dis- 
ablement at ages 15-65, we can calculate what this meant for 
the 819,716 members of the Manchester Unity of Oddfellows 
during the years 1893-97. According to Mr. Watson's tables, 
these men experienced in these years 4,707,680 weeks of sickness, 
of which 941,575 must be attributed to consumption. The 



MAGNITUDE OF THE EVIL 17 

expense to the Oddfellows of this amount of sick relief, and of 
the deaths associated with it, must have been at least half a 
million sterling, and the loss of wages to the men themselves 
at least double this amount. 

At a time when Friendly Societies are finding that the claims 
on their funds are necessitating higher contributions or smaller 
benefits, their wisest policy evidently is to aid by every means 
in their power in diminishing this serious drain on their resources. 

(2) As bearing on the experience of English Friendly Societies, 
facts given by Mr. Hoffman (1901) relating to the experience of 
the Prudential Insurance Company of America may be given. 
He shows that " at the ages of most importance for Industrial 
insurance purposes almost one-half of the entire mortality is due 
to consumption/' His statistics, unfortunately, do not give 
the number of lives at risk, but his facts are nevertheless most 
suggestive. He says : — 

The annual cost of deaths from tubercular diseases to the Prudential 
Insurance Company of America is approximately, on the basis of three 
years' experience, the sum of $800,000. Over 6000 deaths are annually- 
due to this cause in our experience at the present time. . . . While on the 
average we have received $24.00 from those who died from consumption, 
we returned to the beneficiary under Industrial policies over Si 34.00, a net 
loss of about $110.00 on every case, or more than half a million dollars 
during the course of a year. Of course, there is a great difference as to the 
losses sustained at different age-periods, and naturally the income is least 
at the younger ages. As age increases, the average duration of insurance 
increases, and the amounts paid in premiums to the companies tend 
more to approach the amounts paid out in claims, but the fact remains, 
that taking the business as a whole we lose about $110.00 on every death 
from consumption which occurs in our experience at the present time. 
If you examine these facts closely you will realise the great interest of 
the Industrial companies in the problem of diminishing the mortality 
from tuberculosis, especially at the early ages when, as for instance at 
25-29, we will have received $18.00 in premiums to every §1 50.00 paid out 
for losses. 

(3) Dr. Hermann Biggs (1903) after a careful estimate 
places the expense of tuberculosis to the people of the United 
States at $330,000,000 (£66,000,000). He first calculates the 
loss to New York City by putting a value of $1500 (£300) upon 
each life at the average age at which deaths from tuberculosis 
occur. This gives a total value of £3,000,000 for the lives lost 
annually. To this has to be added the loss due to the fact that 



18 THE PREVENTION OF TUBERCULOSIS 

for at least nine months before death these patients cannot 
work ; and the loss of service at $i a day, and the cost of food, 
nursing, medicines, attendance, etc., at $1.50 a day results in 
a further loss of $8,000,000 (£1,600,000), making a yearly loss 
to the city from tuberculosis of $23,000,000 (£4,600,000). The 
estimated annual total of 150,000 deaths from tuberculosis 
in the United States represents in the same way a loss of 
$330,000,000 (£66,000,000). He further points out that the 
total expenditure in the City of New York in the care of tuber- 
culous patients is not at present over $500,000 (£100,000) a 
year — that is, it does not exceed 2 per cent, of the actual loss 
by death, etc. " If this annual expenditure were doubled or 
trebled, it would mean the saving of several thousand lives 
annually, to say nothing of the enormous saving in suffering." 

(4) The experience of the German Imperial Insurance Office 
ascribes a much higher proportion of the total sickness to con- 
sumption than the one-fifth which I have tentatively given on 
the basis of the one-seventh proportion of deaths in the experi- 
ence of the Foresters. Bielefeldt reports that of every 1000 
German workmen aged 20-25 who are rendered unfit for work, 
548 owe their sickness to tuberculosis, while at ages between 25 
and 30 the proportion per 1000 is 521. At the higher ages, as 
the amount of non-tuberculous sickness increases, the proportion 
of tuberculosis becomes less. 

(5) In publications of the National Association for the Pre- 
vention of Tuberculosis, it is estimated that one-eleventh of the 
total cost incurred in the relief of pauperism in England and 
Wales is caused by consumption. The total expenditure in 
poor-law administration in the year ending Lady day 1907 was 
£14,035,888, so that on this basis considerably over a million 
sterling is annually spent on paupers who were made such by 
consumption. 

(6) The experience of the workhouse infirmary of Brighton 
gives some insight into the immense cost incurred in the support 
of parochial consumptive patients. That part of the borough 
of Brighton comprised within the parish of Brighton has a 
population of about 102,000. During the eight years 1897- 
1905, 372 consumptive patients were treated in its infirmary. 
The average and total stay of these patients in the institution 
is shown in the following table : — 



MAGNITUDE OF THE EVIL 



19 



Table IX. — Phthisis 

Brighton Workhouse Infirmary Statistics from July 15, 1897, to 
May 23, 1905 



1. Patient only Once in Work- 
house. 

Number of days under each head- 
ing. 

Number of patients under each head- 
ing. 

Average number of days for each 
patient. 

2. Patient Twice in Workhouse. 

Number of days under each head- 
ing. 

Number of patients under each head- 
ing. 

Average number of days for each 
patient. 

3. Patient Three Times in Work- 

house. 

Number of days under each head- 
ing. 

Number of patients under each head- 
ing. 

4. Patient Four Times in Work- 

house. 

Number of days under each head- 
ing. 

Number of patients under each head- 
ing. 

5. Patient Five Times in Work- 

house. 

Number of days under each head- 
ing. 

Number of patients under each head- 
ing. 

6. Patient Six Times in Workhouse. 

Number of days under each head- 
ing. 

Number of patients under each head- 
ing. 



Total Number of Days spent in Workhouse by 
Patient before — 



Leaving 
Workhouse. 

11,128 



114 

Leaving 

Workhouse 

2nd Time. 

2998 



Leaving 

Workhouse 

3rd Time. 

2146 



Leaving 
Workhouse 
4th Time. 
966 



Leaving 
Workhouse 
5 th Time. 

613 

2 

Leaving 
Workhouse 
6th Time. 
337 



Death. 

21,306 

148 

144 

Death during 
2nd Stay. 

5883 

12 

490 

Death during 
3rd Stay. 

2874 
6 



Death during 
4th Stay. 

3217 
3 



Death during 
5th Stay. 



Death during 
6th Stay. 



May 23, 1905. 
(Still In). 

9133 

18 

507 

May 23, 1905. 
(Still In). 

5521 

4 

1380 



May 23, 1905. 
(Still In). 

261 



May 23, 1905. 
(Still In). 

924 

I 



May 23, 1905. 
(Still In). 



May 23, 1905. 

(Still In). 

3259 
2 



N.B. — The word "Workhouse" is used to include Infirmary. 

The average stay of each patient was 221 days, including those still in. 



20 THE PREVENTION OF TUBERCULOSIS 

This on the basis of 14s. a week x means a total cost for main- 
tenance and treatment of £8221, or an annual cost of over £1000 
a year. If we assume that the expenditure per 1000 of popula- 
tion is the same in other parts of the country as in Brighton, 
this implies that on the indoor relief, i.e. on the institutional 
treatment of consumptives in workhouse infirmaries, an annual 
sum of about £331,000 is spent in England and Wales. This 
estimate makes no allowance for the large sums given in relief 
of the relatives of consumptives both before and after their 
death, and in relief of consumptives who are allowed to remain 
at home instead of going into infirmaries. If these items be 
added together, it is likely that they would exceed the annual 
sum of a million sterling, and would confirm the estimate quoted 
in paragraph (5). 

(7) Farr (1885) stated that the number constantly sick 
to one annual death was 2*8 in the police and in some friendly 
societies. According to the experience of the Manchester Unity 
of Oddfellows during 1893-97 there were 3*35 years of sickness 
for every annual death at ages 20-65. Although consumption is 
more chronic than most disabling forms of disease it is doubtful 
if it causes on an average 3 years of disabling sickness. Doubt- 
less in the above average (3-35 years for every death) is included 
much sick-leave for minor complaints ; and it appears likely 
that the amount of sick-leave given for comparatively slight 
ailments has increased. If, however, we assume that only 
one year's disablement is caused by every fatal case of con- 
sumption, then the direct loss per annum in England and Wales 
produced by the death of men aged 20-65 from consumption, 
reckoning wages at £50 a year, judging by the experience of 1904, 
amounts to £1,015,400. This is the loss in wages, reckoned at 
the above rate. No allowance is made for the cost of the illness, 
for the interference which every sickness involves with the work 
of others, or for the infection of others and resultant further loss 
of health and money. 

The preceding calculations are merely given as illustra- 
tions of the terrible national loss of money and efficiency caused 
by tuberculosis. They fail to show the full extent of the mis- 
chief wrought. Looking at the subject from the standpoint 

1 This is about the average cost in an infirmary calculated separately from 
the workhouse. 



MAGNITUDE OF THE EVIL 21 

of national economics, it is not open to dispute that the most 
elaborate and complete measures of every description against 
tuberculosis would only cost a fraction of the present total 
loss inflicted by this disease, and that this expenditure would 
as time goes on be paid for many times over in the prevention 
of sickness and increase of efficiency of the community. 



CHAPTER III 

ARE THE STATISTICS RELATING TO TUBERCULOSIS 
TRUSTWORTHY ? 

HAVING obtained some idea of the amount of havoc at 
present wrought by tuberculosis, we must — before con- 
sidering the changes in this respect in this and other 
countries — ascertain what degree of confidence can be placed 
in the official statistics of this disease. 

Completeness of Certification of Causes of Death. — 
In drawing deductions from our national statistics, it must 
be borne in mind that, although national registration of births 
and deaths was inaugurated in 1837, it was not until January 1, 
1875, that it became compulsory for medical practitioners to 
give certificates of the cause of death of each patient dying 
under their care. Before this duty became compulsory, medical 
practitioners certified the majority of deaths, but Farr (1885, 
p. 523) notes that in 1871 about 8 per cent, of the total deaths 
were not medically certified. The proportion in 1904 had 
declined to 1/4 per cent. 

There is little doubt that the incomplete medical certification of 
deaths must affect the trustworthiness of the statistics for phthisis 
for years before 1875, though to what extent cannot be stated. 
It is not likely that it does so to such an extent as to make the 
figures before and after 1875 incomparable. This appears to 
follow from the regularity of the fall in the death-rate from 
phthisis before and after this year ; but the gradually increasing 
completeness in medical certification of causes of death needs 
to be borne in mind. 

Beyond this there is the further point as to the gradually 
increasing accuracy of medical certificates. There can be 
little doubt that deaths certified at the present time in this 
country to be due to phthisis are, as a rule, correctly returned. 
The following exceptions to this rule require to be noted : — 



ARE THE STATISTICS TRUSTWORTHY ? 



23 



(a) Inaccurate Diagnosis in Children. — In children, the term 
broncho-pneumonia not infrequently conceals acute tuber- 
culosis, especially when the " broncho-pneumonia " occurs 
after imperfect recovery from such diseases as whooping-cough 
and measles. Coates (1891) has drawn attention to the fre- 
quency of errors of diagnosis in children. He quotes the figures 
of the Great Ormond Street Children's Hospital, London, for 
1877, which showed that of 77 deaths from all causes 35*5 per 
cent, were due to tuberculosis ; and he considers that we may 
safely affirm that of the total deaths under 10 years of age 
among the masses of the people, one-third are due to tuberculosis. 
In Paris, according to Landouzy {Trans. Tuberc. Congr. Paris, 
1888, p. 202), one- third of the deaths under 2 are due to tuber- 
culosis. Compare these statements with the experience shown 
by our national returns for 1904, as given in Table X. 

Table X. 

Percentage at each Age of the total Deaths from all Causes in England 
and Wales in 1904, which were returned as caused by Tuberculosis 
{all forms) 



Aged 


All Ages under 
5- 


Aged 
5-io. 


0-1. 


1-2. 


2-5- 


4-2 


ii'9 


9-2 


6'2 


19-1 



Table V. gives similar facts for phthisis alone. In explaining 
the discrepancy between the percentages in early life given 
in Table X., and the statements made by Coates and Landouzy, 
it has to be remembered that the latter are dealing only with 
hospital statistics, and both probably have included deaths 
in which tuberculosis was secondary to other diseases (e.g. 
whooping-cough), whereas in the Registrar-General's returns 
these would be entered under the heading of the primary disease. 
When allowance is made for these facts, there remains, probably, 
in the national returns considerable understatement of the 
mortality from tuberculosis in early life, which is not com- 
pletely counterbalanced by the return of many deaths as " tabes 
mesent erica," in which there is no tuberculosis. There is no 
evidence that recent statistics of tuberculosis in early life are 



24 



THE PREVENTION OF TUBERCULOSIS 



not fairly comparable with those of past years, and there is 
some evidence to the contrary. 

(b) Inaccurate Diagnosis in Old Age. — Concerning the other 
extreme of life Dr. Glover Lyon has expressed the belief that " if 
all the deaths from senile phthisis were properly registered, the 
registered mortality from phthisis would increase right up to the 
end of life, as is the case in New York." The diminution of 
mortality from phthisis after the age of 60 he believes is entirely 
due to erroneous certification. Dr. Lister also has drawn atten- 
tion to the fact that in cases in which there is senile emphysema 
and bronchitis, great difficulty is often experienced in diagnosing 
phthisis clinically. Error may therefore creep in at these old 
ages. There is no internal evidence to show that in our national 
statistics these possible sources of error have been acting at 
different periods to a markedly varying extent. 

(c) Inaccurate Diagnosis at all Ages. — 1. Confusion between 
Phthisis and other respiratory Diseases. — The most likely sources 
of error in phthisis statistics are deaths returned under the 
headings of bronchitis and pneumonia. In the following table 
the comparative death-rates from these diseases are given for 
a series of years : — 



Table XL — England and Wales 
Death-rates per 100,000 of Population in successive Periods from- 











Bronchitis 






Period. 


Bronchitis. 


Pneumonia. 


and 
Pneumonia. 


Phthisis. 


5 years, 


1866-70 


191 


107 


298 


245 


5 „ 


I87I-7S 








222 


103 


325 


222 


5 » 


1876-80 








238 


100 


338 


204 


5 » 


1881-85 








215 


100 


315 


183 


5 » 


1886-90 








214 


113 


327 


164 


5 „ 


1891-95 








207 


125 


332 


146 


5 „ 


1896-1900 








156 


120 


276 


132 


4 „ 


1901-04 








168 


121 


289 


123 



The question arises whether the rates in Table XL for years 
before 1875 are comparable with the later rates. Comparing 
1871-75 with the two succeeding quinquennial periods, no 
change in the pneumonia death-rate is visible, and little, if 
any, change in the death-rate from bronchitis. The following 



ARE THE STATISTICS TRUSTWORTHY ? 



25 



diagram shows the difference in the course of phthisis and of 
bronchitis and pneumonia together (thus combined because 









































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Fig. 5.— Relative Death-rates from (a) Phthisis, (6) Bronchitis and Pneumonia 
in England and Wales, the rates for 1901-04= 100 



26 THE PREVENTION OF TUBERCULOSIS 

there may have been transference between these two, especially 
between capillary bronchitis and broncho-pneumonia). The 
death-rates from phthisis and from bronchitis and pneumonia 
respectively in 1901-04 are stated as 100, and earlier rates given 
in proportion to this figure. By this method, which is adopted 
in several other instances throughout this work, the items com- 
pared start from a point of the same magnitude, and the varia- 
tions under each heading are comparable on the same scale. 

There is no evidence in Fig. 5 that phthisis has declined in 
consequence of transfer of deaths from that heading to bronchitis 
and pneumonia. The possibility of confusion between pneu- 
monia and bronchitis and phthisis can be further tested by 
a comparison of the age distribution of the death-rates from 
these diseases in 1861-70 with that of 1901. This is done in 
the table on next page for males, and in Fig. 6, which sets out 
the same facts graphically. 

It will be noted that in Fig. 6, and in each of the columns of 
comparative figures in Table XII., the death-rate at all ages in 
the aggregate is stated as 100, and the rates for different age- 
periods are stated in proportion to this. It has not been thought 
necessary to reproduce the table and diagram for the female sex, 
as the result is the same as for males. By means of Fig. 6 we 
can compare for each age-period the relative incidence of fatal 
phthisis and of fatal bronchitis plus pneumonia at each age- 
period in 1861-70 with that in 1901. The comparison is in- 
teresting, as it affords no evidence that there has been any 
considerable transfer between bronchitis plus pneumonia and 
phthisis. Some postponement of the maximum death-rate from 
phthisis is seen in Fig. 6 to have occurred in males, and the 
same change has occurred for females. 

So far, then, as confusion with other diseases is concerned, 
it does not appear likely that the phthisis statistics of recent 
years are to any serious extent incomparable with those of 
earlier years. Phthisis when a fatal disease is easily recognised, 
and the official figures within a limited margin may be regarded 
as approximately true. 

2. Return of Phthisis as " Tuberculosis." — Nor does it appear 
probable that the tendency on the part of doctors which has 
shown itself in recent years, to return deaths as " tuberculosis " 
without any statement of organ affected, has caused a serious 



ARE THE STATISTICS TRUSTWORTHY ? 



27 



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Fig. 6. — Comparison between 1861-70 and 1901 of relative Death-rates at 
different Age-periods from Bronchitis plus Pneumonia and from Phthisis 



ARE THE STATISTICS TRUSTWORTHY ? 



29 



transfer from phthisis. When checking the mortality returns 
of Brighton for three years, I found that 496 deaths were 
returned as phthisis and 39 as tuberculosis, acute tuberculosis, 
or miliary tuberculosis. Many of these, doubtless, had not had 
recognisable pulmonary tuberculosis, and were properly re- 
turned ; and the residuum would only slightly reduce the great 
decline in the death-rate from pulmonary tuberculosis which 
has occurred. Thus, if in the figures for the whole of England 
and Wales, given in Table VI. on page 12, half of the 4315 deaths 
from general tuberculosis were transferred to phthisis, the 
phthisis death-rate would only be changed from 1*24 to 1*30 
per 1000 of population. 

Tuberculous Diseases other than Phthisis. — Tuberculous 
diseases other than pulmonary in 1904 caused 29 per cent, in 
males and 33 per cent, in females of the total deaths from tuber- 
culosis. We must next inquire into the validity of the death- 
returns under these headings. 

Tuberculous Meningitis. — We may adopt the same method 
of age comparison as for phthisis ; only in this instance 1871-80 
must be compared with 1901, because in 1861-70 the decennial 
supplement of the Registrar-General did not separately tabulate 
this disease. 

Table XIII. — England and Wales 

Annual Death-rate from Tuberculous Meningitis per 100,000 Persons 
of both Sexes at each Age-pei'lod 



Age-period. 


1871-80. 


1901. 


0- 

5- 

10- 

15- 

20 and upwards ..... 

All Ages 


190 
30 
12 

5 
1 


109 

27 

12 

6 

2 


32 


18 



There has been a reduction in the death-rate from tubercu- 
lous meningitis (acute hydrocephalus), which corresponds roughly 
with that from phthisis (Table XVI.). Tuberculous meningitis 
is nearly always secondary to other tuberculous diseases, as of 



30 



THE PREVENTION OF TUBERCULOSIS 



the glands or joints. Apart from the presence of such other 
diseases, and unless an autopsy is made, tuberculous cannot 
with certainty be distinguished from other forms of menin- 
gitis. 

Most of the deaths from tuberculous meningitis occur at 
ages under 5. In the following table the death-rates at each 
individual year of the first five years of life at the earliest 
period available in the Registrar-General's reports are compared 
with those for 1901. 



Table XIV. — England and Wales 

Annual Death-rate from Tuberculous Meningitis per 100,000 Persons 
of both Sexes at each Age 



Period. 


Ages. 


All Ages 
under 5. 


All 
Ages. 


0- 


1- 


2- 


3 - 


4- 


1871-80 

1901 

Percentage Decline of Death-rate from 
Tuberculous Meningitis 

Corresponding Percentage Decline of 
Death-rate from Phthisis between 
1871-80 and 1901 .... 


368 
178 


301 
144 


125 

83 


76 
67 


59 
5o 


190 
109 


32 
18 


52 


52 


34 


12 


15 


43 


47 


65 


62 


5i 


46 


5o 


60 


4i 



It will be noted that both in 1871-80 and in 1901 the death- 
rate from tuberculous meningitis at ages under 5 was about six 
times that at all ages. This appears to indicate that the statistics 
of the two periods are comparable. Of course it does not follow 
that they are accurate, and the comparisons given in the two 
lowest columns of Table XIV. of percentage declines in the 
death-rate for each of the first five years of life with those of 
phthisis, throw further doubt on this point. The statistics of 
tuberculous meningitis in the first year of life are especially 
open to doubt. H. Armstrong (1902) states that the post- 
mortem records for eighteen years at the Liverpool Infirmary 
for Children contain particulars of 85 necropsies in which tuber- 
culous meningitis was found. Of these 10 were in the second year, 



ARE THE STATISTICS TRUSTWORTHY ? 



3i 



18 in the third year, and not one in the first year of life. 
Fagge states that only three cases of tuberculous meningitis 
in the first year of life were verified in Guy's Hospital in forty 
years. 

Tabes Mesenterica and Tuberculous Peritonitis. — 
Tabes mesenterica is a name which should correctly be applied 
only when it is clear that the patient has tuberculous disease of 
the abdominal lymphatic glands. Unfortunately it is often used 
in death certificates when the patient has died from a slow 
wasting disease accompanied or not by abdominal symptoms 
such as diarrhoea. As Drs. Ashby and Wright state in their 
work on Diseases of Children, " Mesenteric disease is much 
more frequently diagnosed than discovered post-mortem." 
Similarly, Dr. Donkin (Brit. Med. Journ., vol. ii. p. 1046, 1899), 
says, " All kinds of intestinal and other disorders are constantly 
styled tabes mesenterica by those who fail to cure them/' The 
usual condition mistaken for it is wasting or marasmus caused 
by chronic gastro-intestinal catarrh. In the great majority of 
fatal cases of tabes mesenterica, this disease is accompanied by 
general tuberculosis. Tabes mesenterica is seldom and tuber- 
culous peritonitis still less frequently a direct cause of death. 
In the following tables these two diseases are included together. 
The separate tabulation of tuberculous peritonitis in the Registrar- 
General's returns was not begun till 1901. 

Table XV. — England and Wales 

Annual Death-rate from Tabes Mesenterica and Tuberculous Peritonitis 
per ioOjOoo Persons of both Sexes at each Age-period 



Age-period. 



o- 

5- • 
10- 
15- . 

20 and upwards 

All Ages . 



:87i-8o. 



32 



1901, 



203 


125 


13 


10 


8 


7 


6 


5 


3 ' 


3 







19 



Here again there has been a reduction in the death-rate 



32 



THE PREVENTION OF TUBERCULOSIS 



similar to that in phthisis. The comparison for each of the first 
five years of life is shown in the following table : — 

Table XVI. — England and Wales 

Annual Death-rate from Tabes Mesenterica and Tuberculous Peritonitis 
per 100,000 Persons of both Sexes at each Age 



Period. 


Ages. 


All Ages 
under 5. 


All 
Ages. 


0- 


1- 


2- 


3- 


4- 


1871-80 

1901 

Percentage Decline of Death-rate from 
Tabes Mesenterica .... 

Corresponding Percentage Decline of 
Death-rate from Phthisis between 
1871-80 and 1901 .... 


533 
364 

32 
65 


296 
138 

53 
62 


88 
47 

47 
5i 


36 
25 

3i 


21 
17 

19 


203 
125 


32 
19 


38 


41 


46 


5o 


60 


41 



It will be noted that under i year of age the death-rate 
from tabes mesenterica declined 32 per cent. This should be 
especially noted because Thorne in his Harben Lectures for 1895, 
comparing 1891-95 with 1851-60, showed an increase in the 
infantile death-rate under this head of 277 per cent, and founded 
on it an important inference as to the importance of bovine milk- 
supply in the causation of tabes mesenterica. In view of the 
opposing experience when 1871-80 is compared with 1901, the 
only inference justifiable is that the statistics of infantile tabes 
cannot be trusted. The general experience of pathologists is 
that the number of deaths from tabes increase as the end of the 
first year of life approaches. Compare with this the fact that of 
the 2977 deaths registered in 1901 as caused by tabes mesenterica, 
594 were at ages under 3 months, 1036 at ages 3-6 months, and 
1347 at ages 6-12 months. Evidently many of the deaths 
returned as tabes mesenterica would be found to be due to causes 
other than tuberculosis were all death certificates verified by 
autopsies. 

Although there is a close correspondence in the aggregate 
for all ages between the declines in the death-rates from phthisis 



ARE THE STATISTICS TRUSTWORTHY ? 



33 



and from tabes mesenterica, this is not consistently so at the 
earlier ages, and we must regard the statistics of this disease 
as on a plane of trustworthiness much inferior to that occupied 
by the statistics of phthisis. 

Comparisons of Decline in Different Tuberculous Dis- 
eases. — Mention has been made of the parallelism of movement 
of the death-rates from each of the forms of tuberculosis which 
are tabulated separately by the Registrar-General. This point 
is worthy of further study, in view of the side-light thrown by it 
on the trustworthiness of the statistics. 



Table XVII. — England and Wales 

Annual Death-rate per 100,000 Persons of both Sexes from each of the chief 

Forms of Tuberculosis 



Period. 


Phthisis. 


Tuberculous 
Meningitis. 


Tabes 
Mesenterica. 


Scrofula. 


5 years, 


1850-54 


281 


43 


27 


15 


5 » 


1855-59 






265 


39 


26 


15 


5 » 


1860-64 






257 


37 


27 


16 


5 >> 


1865-69 






253 


35 


32 


14 


5 » 


1870-74 1 






228 


32 


3° 


12 


6 „ 


1875-80 






208 


28 


34 


14 


5 » 


1881-85 






183 


26 


29 


16 


5 »> 


1886-90 






164 


24 


27 


18 


5 » 


1891-95 






146 


23 


24 


19 


5 >, 


1 896- 1 900 






132 


21 


20 


18 


4 » 


1901-04 


123 


19 


17 


17 



If we reduce the four columns of death-rates to the same 
scale by giving each rate for 1901-04 as 100, and state all the 
other rates in each column in proportion to this, a more exact 
comparison can be made. The result is shown in Fig. 7. Evi- 
dently the somewhat less trustworthy rates for tabes have 
not consistently followed the law of decline which is shown 
to an almost equal extent by phthisis and tuberculous menin- 
gitis. 



1 The figures up to 1879 are taken from the Annual Report of the Registrar- 
General of Births and Deaths for 1880, p. lxxix. The classification was altered 
in 1 88 1, and the returns for scrofula before and after 1880 are not comparable. 
After 1880 the last column in Table XVII. includes lupus, tubercle of other 
organs, and general tuberculosis as well as scrofula. 



34 



THE PREVENTION OF TUBERCULOSIS 



230 
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Fig. 7. — Relative Death-rates from different Tuberculous Diseases from 1850-54 
to 1901-04, the Death-rate in the most recent period in each instance being 
stated as 100 



CHAPTER IV 
THE HISTORY OF PHTHISIS 

UNTIL the eighteenth century medical men confused under 
the names of phthisis or its English equivalent consump- 
tion all the acute and chronic diseases of the trachea, 
bronchi, lungs, pleurae, and lymphatic glands when these were 
accompanied by progressive debility and emaciation. In read- 
ing the old descriptions of phthisis it is not difficult, however, 
to recognise that pulmonary tuberculosis formed a large portion 
of this congeries, and it is not without interest to trace, however 
sketchily, the views as to the nature of phthisis which have been 
held in different generations. We may deal first with what may 
be described as the Pr.e-anatomical Period, in which post- 
mortem dissections were rare, and in which views as to the nature 
of phthisis were based almost solely on the symptoms recognised 
during life. 

Hippocrates (460-377 B.C.) described the disease, ascribing 
it to a suppuration of the lungs, which may arise in various 
ways. Galen (130-200 a.d.) also described it, and believed it 
so infectious that it was dangerous to pass an entire day in the 
company of a phthisical person (Walshe, p. 459). Hippocrates, 
Galen, Aretseus [circa 50 B.C.), and Celsus [circa 30 B.C.) all de- 
scribed the disease, but not one of them appears to have recognised 
the existence of the tuberculous nodules which form its char- 
acteristic lesion. With the discovery of these we arrive at the 

Anatomical Period. — Franciscus D. Sylvius (1614-1672 
a.d.) was the first to recognise the causal relation of these 
nodules to phthisis, so that the first step towards accurate know- 
ledge of its pathology may be said to have been due to the 
making of autopsies, which became fairly frequent in the 
seventeenth century. Sylvius thought the nodules to be the 
lymphatic glands of the lungs, and thus to be analogous to 
scrofulous growths. Much speculation was devoted to these 



36 THE PREVENTION OF TUBERCULOSIS 

nodules ; and in the year 1700 Magnetus first described the 
more minute nodules known as miliary tubercles, comparing them 
to millet seeds, and showing their presence in the kidneys, liver, 
and spleen, as well as in the lungs. Morgagni (1682-1772) dis- 
puted the glandular nature of tubercles; Thomas Reid (1778) 
wrote of them as being not enlarged glands, but the products of 
exudation. Matthew Baillie (1793) gave the following de- 
scription of tubercles : — 

Tubercles are firm white bodies interspersed through the substance 
of the lungs, and apparently formed in the cellular structure ; for nothing 
like a gland is to be discovered in the cellular membrane of the lungs in a 
healthy state; and the follicles of the bronchi are not converted into 
tubercles ; they are first very minute ; the clusters probably unite and 
form larger masses ; the most common in size is that of a garden pea ; 
they are firm in their consistence, and often contain a portion of thick 
curdy pus. . . . 

Thus Baillie recognised that the large nodules in tuberculosis 
are produced by fusion of smaller tubercles. He described the 
cheese-like substance of these large nodules as scrofulous matter, 
recognising it and pus as the two characteristic products of 
advanced tuberculosis. At the same time he attempted to 
distinguish between caseating pneumonia and tubercles in a 
condition of caseation. 

Bayle (1774-1816), the precursor and teacher of Laennec, 
published in 1810 the records of 109 autopsies on tuberculous 
patients, and traced the minute tubercles through the subse- 
quent stages of suppuration and caseation. He was of opinion 
that phthisis was a disease not peculiar to the lungs but de- 
pendent on a tuberculous diathesis or special constitutional 
tendency. 

Laennec (1781-1826) made investigations and published 
teaching on tuberculosis which has been well described as a 
tour-de-force of objective analysis. He taught that every 
phthisis develops from tubercles, and that phthisis and tuber- 
culosis are interchangeable terms, the tubercle being a new 
product which appears either in isolated nodules or infiltrated 
through the tissues. In both forms, he showed that it was 
first grey and hyaline, gradually becoming opaque and very 
dense, and later softening and discharging its contents through 
the bronchi, leaving cavities in the substance of the lungs. 



THE HISTORY OF PHTHISIS 37 

Scrofulous glands were merely tuberculosis confined to the 
lymphatic glands. Laennec denied the inflammatory origin of 
tuberculous matter, and especially the transformation of pneu- 
monia into tuberculosis. He was very sceptical also as to the 
causation of tuberculosis by bronchial catarrh. In these respects 
modern pathology has in the main confirmed his marvellous 
insight. 

Although Laennec's views were adopted by Louis in France 
and by Hughes Bennett and others in Great Britain, the tyranny 
of error gradually overshadowed Laennec's teaching, and what 
is known as the dualist theory prevailed. According to this 
theory, which cannot even now be said to be entirely abandoned, 
most of the lesions of tuberculosis are not due to the tubercles, 
but are primarily inflammatory in origin, the tubercles being 
secondary to the inflammatory changes. Niemeyer formulated 
this view in the words, " The greatest danger to which a 
phthisical patient is exposed is that of becoming tuberculous." 

The Period of Microscopical Investigation began about 
1840, and although it did not solve the problem of the patho- 
logical unity between caseous pneumonia and miliary tubercu- 
losis, it was not fruitless. In 1844, Lebert thought he had found 
distinctive tubercle corpuscles in the tubercles. Rokitansky, 
whose book on Pathological Anatomy first appeared in 1842, 
declared that tubercles were new growths composed of inspissated 
proteins. The doctrine of " dyscrasia " or evil constitutional 
conditions was then to the fore, and as a follower of this teaching 
Rokitansky considered the " tuberculous habitus " to be very 
important. 

In 1847, Reinhardt showed that the so-called tubercle 
corpuscles may originate from pus cells, thus diminishing their 
importance. In the same year Virchow did much to buttress the 
dualist theory by teaching that the process of caseation is not 
peculiar to tuberculosis. In 1852 he limited the term " tubercle " 
to miliary tubercles, which he described as new growths sub- 
sequently changed by caseation, calcification, or fatty degenera- 
tion followed by absorption. He is chiefly responsible for the 
dualist theory which has done much to hinder the progress of 
investigation. 

A step towards unlearning this erroneous teaching was taken 
when Buhl in 1857 showed that in at least 90 per cent, of his 



38 THE PREVENTION OF TUBERCULOSIS 

cases of tuberculosis in the lungs pre-existent caseous masses 
were present somewhere in the body. He attributed the tuber- 
culosis to these cheesy foci, infective products from which had 
gained admission to the blood and then formed tuberculosis in 
the lungs or disseminated miliary disease in various organs. 
Here we have the first clearly expressed conception of miliary 
tuberculosis as a self-infection caused by the absorption and 
distribution of infective material derived from older foci in the 
patient himself. 

Although Laennec's teaching led to scrofula being commonly 
regarded in France as the same disease as tuberculosis, in other 
countries the belief in its separate origin has only recently dis- 
appeared. 

The adoption of Experimental Methods of Investigation 
of tuberculosis led to further advance towards precision of 
knowledge. From remote times the view that phthisis was 
an infectious disease had occasionally been taught (p. 55). 
Some early attempts at producing artificial infection were not 
successful, and Klencke's successful experiments in 1843 were over- 
looked. He injected tubercle cells taken from miliary tubercles 
into the jugular vein of rabbits, and twenty-six weeks later 
at the autopsy found widespread tuberculosis of liver and lungs. 

Villemin's epoch-making experiments were published on 
December 5, 1865. He inoculated rabbits subcutaneously 
behind the ear with matter taken from grey and yellow human 
tubercles, and found that (1) animals thus inoculated developed 
pulmonary tuberculosis, (2) control animals which had not 
been inoculated remained free from tubercle, and (3) other 
animals similarly inoculated with pus from non-tuberculous 
patients did not develop tuberculosis. Later on he obtained 
results similar to those given under (1) by inoculating with 
caseous material from tuberculosis, with the sputum of con- 
sumptives, and with tuberculous material from a cow. Villemin 
summed up the contents of his note to the Academie de Medecine 
in the following words : " (1) Tuberculosis is the effect of a 
specific causal agent, in short of a virus. (2) This agent must 
reside like its congeners in the morbid products formed by its 
direct action on the normal elements of the affected tissues. 
(3) Introduced into an organism susceptible to its action, it must 
continue to reproduce itself, and at the same time to reproduce 



THE HISTORY OF PHTHISIS 39 

the disease of which it is the essential principle and the determin- 
ing cause. Experiment has confirmed these results of induction." 
He added: "Tuberculosis is a specific affection, caused by an 
inoculable agent. Tuberculosis belongs then to the class of 
virulent diseases, and in the nosological scheme must take its 
place beside syphilis, but closer still to glanders." 

The Academie de Medecine was not convinced. During the 
following year Villemin worked continuously on new experiments, 
and on October 30, 1866, reopened a discussion on the same 
subject. Having been accused previously of experimenting on 
rabbits already tuberculous, he took in his new experiments 
animals of different species. His inoculation experiments suc- 
ceeded in nine out of nine rabbits, in two guinea-pigs, in a dog 
and in a cat. A sheep, a cock, and a pigeon remained immune. 
Having by his extended basis of operation eliminated the element 
of chance, he reaffirmed his conclusions, and a commission under 
Colin was appointed by the Academie to investigate his results. 
In its report of July 1867 it refused to accept Villemin's con- 
clusions. 

They were true notwithstanding ; and to Villemin belongs 
the immortal fame of being the first to show the essential dis- 
tinction in tuberculosis between the virus causing the disease and the 
lesions produced by it. In 1868 he published his Etudes sur la 
Tuber culose in which he further answered objections, vigorously 
defended the idea of contagion, and argued against the existence of 
a special tuberculous diathesis, a view which at that time domin- 
ated and still influences medical minds to a great extent. 

Villemin's experiments were repeated by others with varying 
results. Progress was retarded by the fact that in some experi- 
ments tuberculosis followed the inoculation of pus, particles of 
sponge, and other apparently non-tuberculous materials. Burdon 
Sanderson in 1868-69 confirmed Villemin's work, and the follow- 
ing extract from one of his reports to the Medical Officer of the 
Privy Council shows the stage to which he had brought the 
investigation : — 

As regards the question of a specific contagium of tubercle, we 
think it very important to note that this is not as yet disproved by the 
facts of traumatic tuberculosis. It still remains open to inquiry whether 
or not injuries which are of such a nature that air is completely excluded 
from contact with the injured part are capable of originating a tuberculous 



40 THE PREVENTION OF TUBERCULOSIS 

process. The results of the following experiments undertaken at the 
instance of Mr. Simon, with special reference to this question, seem in- 
deed to suggest that they may not be so. Setons steeped in carbolic 
acid were inserted in ten guinea-pigs on the 24th of September 1868, 
each animal receiving two. At the same time extensive fractures of both 
scapulae were produced on five others, care being taken not to injure 
the integuments. No tuberculosis or other disease of internal organs 
resulted in either case : these facts certainly point to the necessity of further 
investigation in this direction. 

In 1876, when Simon ceased to be Medical Officer to the 
Local Government Board, the specific infectivity of tuberculosis, 
and the question whether this infectivity was dependent on a 
specific organism, were matters which occupied the attention of 
pathologists in all parts of the world ; but neither question had 
been settled experimentally. Further trials by Chauveau and 
Klebs in 1873 and by Baumgarten and Cohnheim in 1880 showed 
that the discrepant results referred to above were caused by 
faulty experimentation involving accidental infection of the 
animals. Thus Cohnheim had in the first instance concluded 
that tuberculosis is not a specific process. In a second series of 
experiments, however, he inoculated animals in the anterior 
chamber of the eye. By this means he was able to follow each 
stage of evolution of tuberculosis of the iris and cornea, and to 
establish fully its specific character. On the strength of these 
experiments he foretold the early discovery of the parasitic 
agent of tuberculosis. Before this discovery was made H. 
Martin showed that the nodules produced by foreign bodies 
were not inoculable in other animals, whereas true tubercles were 
re-inoculable without any diminution in virulence. Thus the 
specificity of tubercle was further demonstrated by its con- 
tinuous inoculability in a series of animals. William Marcet 
repeated Villemin's results by inoculation of guinea-pigs with 
tuberculous sputum, and failed to produce similar results with 
bronchitic sputum ; and he stated rightly that an inoculated 
guinea-pig might thus serve as a means of diagnosis in doubtful 
phthisis. 

Before the final proof of the specificity of tuberculosis was 
given, much advance was made in our knowledge of its methods 
of spread. Chauveau proved that tuberculosis could be pro- 
duced by eating meat, etc., containing tuberculous material, and 
concluded that human and bovine tuberculosis were identical. 



THE HISTORY OF PHTHISIS 41 

He also showed that it was the particulate part of morbid secre- 
tions which was capable of spreading infection. Villemin had 
made the statement that tuberculosis could be spread by inhala- 
tion of the virus, and pointed out the role of dried expectoration 
in its dissemination ; and Tappeiner was the first to demonstrate 
on dogs the possibility of dissemination of infection in this 
way. 

Pasteur's work rendered it likely that tuberculosis was due 
to bacteria. It was found that the basic aniline dyes had a special 
elective affinity for bacteria, staining them deeply. Ordinary 
staining by this means failed to show bacteria in the morbid 
growths of tuberculosis, but after various attempts Robert 
Koch succeeded in staining the bacilli of tuberculosis by first 
adding a small quantity of an alkali to the aniline stain, and thus 
rendering it capable of penetrating the resistant outer membrane 
of the tubercle bacillus. Other means of obtaining the same 
result were subsequently discovered ; and a distinctive fact of 
great importance was discovered, when it was found that even 
strong mineral acids, which decolorised other stained bacilli, 
failed to discharge the colour from the tubercle bacillus. 

On the 24th March 1882, Koch contributed to the Physio- 
logical Society of Berlin his note on " The Discovery and Cultiva- 
tion of the Bacillus of Tuberculosis/' He isolated, cultivated 
outside the body, described, and differentiated the infective 
organism of tuberculosis, and proved that it could continue to 
produce the same lesions indefinitely. By a method of double 
coloration, he showed the bacilli coloured blue on a brown 
ground of vesuvin. He showed their presence in all known 
tuberculous lesions and in tuberculous expectoration, and demon- 
strated the virulence of the tubercle bacillus in expectoration 
which had been dried for eight weeks. 

Having thus traced the steps by which the crowning demon- 
stration of the inf ectivity and of the infective agent of tuberculosis 
was obtained, it will be convenient to summarise briefly the 
pathological and clinical features of the disease produced by the 
bacillus, and next to describe its biology, before dealing more 
fully with the questions of infectivity and the conditions govern- 
ing the spread of infection. 

In looking back on the history of tuberculosis, three names 
stand out pre-eminently — Laennec, Villemin, and Koch. It is 



42 THE PREVENTION OF TUBERCULOSIS 

chiefly to these three men, — the last of them aided by the wonder- 
ful work of Pasteur and his followers, — that we owe the discovery 
that tuberculosis is an entirely preventable disease. On their 
work is based our exact knowledge of the nature of tuberculosis, 
and the more accurate means for its prevention which we now 
possess. 

The history of phthisis since statistics became available is 
given in the course of the argument of Part II. (p. 21 z)el seq.). 



CHAPTER V 
THE MORBID ANATOMY AND SYMPTOMS OF PHTHISIS 

THIS work deals solely with tuberculosis from the point 
of view of preventive medicine and public health. Even 
when we come to consider the sanatorium treatment 
of consumptives, this will be chiefly considered as a means 
of preventing others from becoming consumptive. Notwith- 
standing this intentional limitation, the subject cannot be 
discussed fully unless a short description of the pathology 
and symptoms of tuberculosis is given. Such a description 
is necessary not only before we can estimate the value of 
sanatorium treatment, but also in order that the means of 
spreading and preventing the spread of infection, and particu- 
larly the phenomenon of latency, may be understood and their 
importance appreciated. 

Pulmonary tuberculosis is caused by the invasion of the 
lungs by the tubercle bacillus. The terminal bronchioles end- 
ing in the minute air vesicles or alveoli have a diameter of from 
3 to 4 tenths of a millimetre, while the tubercle bacillus measures 
from ij to 3 thousandths of a millimetre in length. So far 
therefore as size is concerned, there is no difficulty in the tubercle 
bacillus being drawn by inspiration into the air vesicles, where 
it produces its evil results. 

The Commencement of the Invasion. — The method by 
which the bacilli reach the alveoli, whether by inspiration, by 
spread from the lymphatic glands near the root of the lung, 
by the blood circulation, or in all these ways at different times, 
will be considered subsequently. 

From the very commencement of the attack the tubercle 
bacillus meets with resistance. Its opponents are some of the 
wandering or patrol cells of the body ; in the earlier stages 
they consist almost entirely of amceboid cells or leucocytes, 
derived from the blood and the marrow ; at a later stage larger 



44 THE PREVENTION OF TUBERCULOSIS 

wandering amoeboid cells are produced by, the rapid prolifera- 
tion of ordinary non-wandering connective tissue cells and 
of the cells lining the alveoli or air vesicles. Both kinds have 
the power of ingesting foreign substances, and are called 
phagocytes. 

Attracted chemically by soluble substances produced by 
the bacilli, phagocytes migrate into the invaded area, and there 
attack the invaders in two ways, (i) Under the irritation due 
to bacterial toxins they throw off into solution complex sub- 
stances called antibodies. These may act either by neutralising 
the toxins, in which case they are called antitoxins ; or by 
destroying the bacterium itself. (2) The phagocytes push 
delicate fingers of protoplasm round the bacteria, which are 
thus enveloped and afterwards absorbed. The importance 
of this process of phagocytosis was first emphasised by 
Metchnikoff. Sir Almroth Wright has recently shown that 
phagocytes cannot absorb bacteria unless the latter have been 
acted on previously by specific substances present in the fluid 
part of blood. These substances he has called opsonins. They 
are, like other antibodies, produced by the tissue cells and 
leucocytes. In normal blood they are present in approxi- 
mately constant proportion, but great variations occur in 
disease. The bacillus therefore is opsonised by the surround- 
ing exuded plasma ; its vitality is not affected, but it is in some 
unknown way rendered absorbable by phagocytes. 

The Progress of the Invasion. — If the invasion is small 
and the leucocytes lusty, the invaders are vanquished. But 
otherwise the invasion progresses. Leucocytes are killed by 
the bacterial toxins, and their dead bodies accumulate as pus. 
The leucocytes may even be a source of danger to the body. 
They may pass with their load of bacteria into the surround- 
ing tissues, and here, owing to their supply of intracellular 
antibodies being insufficient, they may be destroyed by the 
living bacteria within them, so that the bacteria are again free, 
like the Greeks from the wooden horse in the siege of Troy. 
It is at this point that we have to take up our description of the 
lesions produced by tuberculosis. 

The Lesions in Tuberculosis. — The tubercle bacilli have 
entered the body and the leucocytes have failed to kill them. 
The earliest and most characteristic lesion produced is the 



MORBID ANATOMY AND SYMPTOMS OF PHTHISIS 45 

grey tubercle. Its size varies from a pin's point to a pin's head, 
or occasionally it may be as large as a small pea. It is grey 
and slightly translucent. Under the microscope it is seen to 
consist of a group of small and large cells containing tubercle 
bacilli. The grey tubercles gradually become converted into 
yellow tubercles, which are opaque, slightly granular, dry and 
friable. They increase in size by coalescence, and then further 
changes occur. Both grey and yellow tubercles are destitute 
of blood vessels, but their presence causes inflammatory 
changes in the surrounding vascular tissues. This often ends 
in suppuration with the formation of an abscess, whose contents 
find their way into the nearest bronchiole and are expectorated. 
The cavity thus produced in the lung may go on discharging 
muco-pus for years. It may join with other cavities to form 
larger cavities ; the discharge from which produces gradual 
exhaustion of the patient, while the toxic products absorbed 
from them into the circulation produce the characteristic hectic 
temperature of phthisis. Occasionally severe haemorrhage 
(haemoptysis) occurs owing to the bursting of a blood vessel. 
The cavity, if single, may gradually contract and heal. Many 
consumptives with such cavities in their lungs have under 
favourable conditions survived and worked for many years. 

The change from grey to yellow tubercle is due to caseation, 
a process so called because the diseased part has a cheesy appear- 
ance and consistence. In chronic cases the caseous material 
may become calcified, and at this stage the process may stop. 
In small tubercles fibrous changes may occur, the diseased part 
being converted into fibrous tissue. 

Three figures in Hughes Bennett's Lectures on the Principles 
and Practice of Medicine (ed. 1859) so clearly illustrate the 
three stages of tuberculosis of the Jungs that I have reproduced 
them here. Fig. 8 shows the formation of grey tubercles and 
some yellow tubercles. At the apex of the lung some of the 
latter have broken down into an imperfect cavity. 

In Fig. 9 a lung is shown in a more advanced condition 
of disease. Tuberculosis is extensively infiltrated in the upper 
lobe, and a considerable cavity has formed. 

In Fig. 10 the third or last stage of pulmonary tuberculosis 
is shown. The upper half of the lung is occupied by an 
enormous cavity, and a smaller cavity has been excavated 



46 THE PREVENTION OF TUBERCULOSIS 

in the lower lobe. Very often the patient does not survive 
long enough to show such extensive disease. Happily the 
history of a large number of cases of pulmonary tuberculosis 
is not correctly depicted in Figs. 8 to 10. There may be 
only one or a few of the white dots (grey tubercles) shown in 
Fig. 8, and these may completely heal by calcification or fibrosis. 
In fact in very few cases of phthisis is the destructive process 
continuous. As Hughes Bennett (p. 715) puts it : — 

It is continuously checked, and for a time slumbers ; and all morbid 
anatomists have recognised, even in the worst specimens of tubercular 
lungs, numerous cicatrices and evidences of attempts to heal. These 
attempts are more or less perfect, and when ineffectual, it is owing to the 
circumstance that as one portion of lung cicatrises, another becomes the 
seat of recent tubercle. 

In Fig. 11, taken from the same source, the upper portion 
of a right lung is shown, in which are calcareous masses occupy- 
ing the place where formerly was active tuberculous disease. 

As a rule, except in children, the top of the lung is first and 
chiefly diseased. The explanations given of this fact are not 
altogether satisfactory, but it is probable that the anatomical 
distribution of the bronchial tubes gives the key to the problem. 
The apical bronchi take a very steep direction upwards ; and 
this implies that in expiration there is a dead point here, and 
that in coughing a backward air current may easily drive 
foreign matter into these relatively inactive regions. The 
fact that in children apical phthisis is less common may be 
due to the fact that in them the upper part of the lung is rela- 
tively short and the apical bifurcation of bronchi less steep ; 
but it is also explicable on the supposition that in children 
invasion of the lungs from the lymphatic glands at their root 
is more common than in adults. 

How Tuberculosis spreads in the Lungs. — This occurs 
often (a) through the air passages. When a cavity is formed and 
its contents are being expectorated from any one point, it is 
easy to understand how some of the semi-purulent expectoration 
can be drawn into the tubes of healthy parts of the lungs. Here 
it sets up caseating broncho-pneumonia, the lesion which pre- 
dominates when animals are rendered artificially tuberculous 
by the inhalation of tuberculous spray. Such cases in man 
usually progress rapidly. Disease also commonly spreads (b) 




FIG. 9 



MORBID ANATOMY AND SYMPTOMS OF PHTHISIS 47 

by infection of the lymphatics. Phagocytes ingest tubercle bacilli 
from the yellow tubercles, and then pass on into the neighbouring 
lymphatic vessels. In these vessels or in the glands fed by them 
such phagocytes as perish release the contained tubercle bacilli, 
and thus infect neighbouring parts. Hence around a caseous 
mass are often seen more recent grey and yellow tubercles. The 
lymphatic glands at the root of the lung are also involved early. 
(c) If the infective material gains access to the blood vessels, as 
when a tuberculous growth erodes the coat of a vessel, bacteria 
are disseminated by the circulation of blood either to other parts 
of the same lung or throughout the body, producing general 
tuberculosis. 

Symptoms of Phthisis. — From the preceding description of 
the lesions found in fatal cases of phthisis the symptoms of the 
fully established disease may be gathered. An irritating cough, 
accompanied by abundant expectoration of muco - purulent 
material, in which tubercle bacilli can usually be found ; hectic 
fever ; copious cold sweats at night ; and rapid emaciation. 

The symptoms of onset are commonly very insidious. The 
patient is languid, suffers from increasing weakness, and is often 
thought to be suffering from " anaemia." Anaemia with a dry 
cough in most instances means early phthisis. Sometimes 
profuse haemoptysis is the earliest symptom recognised, and it 
is often the first symptom which induces a patient to consult 
a doctor. This symptom always means that an already formed 
tubercle, usually a caseous mass, has ulcerated into a blood 
vessel, and indicates therefore older tuberculous disease. 

At certain stages of phthisis there may be no expectoration, 
and this does not always imply that active mischief is in abey- 
ance. Cases with expectoration are described by German 
doctors as " open," those without as " closed " ; the distinction 
is important, as the latter are relatively non-infective. Pro- 
gressive cases all become " open " sooner or later. 

Varieties of Phthisis. — The great majority of cases belong 
to the chronic variety. Some are very acute, the whole case 
only lasting from a few weeks to three or four months. Such 
cases often resemble pneumonia, and some are so acute as to 
simulate enteric fever. Of the chronic form of disease, some 
show progressive deterioration, ending fatally in from six to 
twelve months ; others have repeated acute attacks, with in- 



48 THE PREVENTION OF TUBERCULOSIS 

tervals of apparent recovery and quiescence, the intervals be- 
coming shorter as time progresses ; in others a sharp attack 
occurs, and the patient then permanently recovers. To these 
must be added a large number of unrecognised cases, in which 
recovery occurs, and in which it is difficult to obtain any history 
of lung disease. The patient may have been " off colour " for a 
time, may have been anaemic, and may have had a slight cough. 
He then " recovers by encapsulation, unaware that the shadow 
of the black hawk's wing had rested upon him " (Allbutt, p. 1152) . 
Further particulars of such cases are given, pp. 82 to 84. 

The Curability of Phthisis. — The vast majority of 
attacks of phthisis are followed by recovery. This fact cannot 
be too strongly emphasised. It is not a new fact discovered 
since the open-air treatment of the disease came into vogue, but 
has been known to pathologists and physicians from time im- 
memorial. Hippocrates taught that " phthisis, if treated early 
enough, gets well. ,, In modern times Carswell (quoted by 
Brouardel, p. 66) wrote in 1838 : " Pathological anatomy has 
never, perhaps, given a more decided proof of the cure of a disease 
than it gives in cases of pulmonary phthisis." 

Hughes Bennett (p. 716) says : — 

In 1845, 1 made a series of observations with reference to the cretaceous 
masses and puckerings so frequently observed at the apices of the lungs 
in persons advanced in life. The conclusion arrived at was, that the 
spontaneous arrestment of tubercle in its early stage occurred in the pro- 
portion of from one-third to one-half of all the individuals who die after 
the age of forty. The observations of Rogee and Boudet, made at the 
Salpetriere Hospital in Paris, amongst individuals generally above the age 
of seventy, showed the proportion in such persons to be respectively one- 
half and four-fifths. 

According to Charcot, " phthisis is susceptible of cure com- 
pletely and definitely even at the period of cavities." Brouardel 
quotes Laennec, Nat. Guillot, and Letulle as showing that in 
more than half the post-mortem examinations made by them 
old healed tuberculous lesions were to be found. 

Commenting on these results Dr. Ribard says : — 

These figures, from the similarity even of their results, are striking. 
They show very clearly that half the men, said to be well and non- tuber- 
culous, dying of old age or fortuitous causes, have at a certain time in 
their life been attacked by tuberculosis but have recovered. Many are 



MORBID ANATOMY AND SYMPTOMS OF PHTHISIS 49 

therefore affected, and many recover, if half the human race have tubercle 
and go on living without discovering them. Such is the truly reassuring 
result of autopsies. 

Dr. Thomas Harris of Manchester (1889) taking the deaths of 
persons over 20 years of age who died in the Manchester Royal 
Infirmary found healed phthisis (" involuted tuberculosis ") in 
about 38 per cent, of the post-mortem examinations made by him. 

Coates (1891, p. 351), after giving an account of 131 consecutive 
autopsies at the Glasgow Royal Infirmary, says : "It appears 
that, taking even the most serious forms of internal tuberculosis, 
such as consolidation of lungs, tuberculous disease of the verte- 
brae, tuberculosis of the peritoneum, there is evidence that 
spontaneous recovery takes place in a proportion equal to that 
in which death occurs." 

Austin Flint (1882), after analysing 670 cases of phthisis 
in his practice, concluded that " in a certain proportion of 
cases this disease ends favourably irrespectively of any ap- 
preciable extrinsic agencies." He draws attention as follows to 
the self -limitation which is exemplified in the majority of fatal 
cases (p. 617) : — 

The disease, as a rule, advances not by a continuous progress, but by 
a series of successive invasions separated by variable intervals. After 
each invasion, or as it has been termed tuberculous eruption, there is a 
temporary self-limitation of the disease. 

The continuous advancement of the disease as an exception to the 
rule is the pathological feature of the so-called " galloping consumption " 
or phthisis rlorida. 

Duration of Phthisis. — From the preceding pages it is 
evident that the duration of phthisis is very variable. It is 
interesting to note the estimates of its duration given by different 
authors. According to Austin Flint it may vary from three 
weeks to forty years. Similarly Portal said " eleven days to 
forty years." Laennec gave its average duration excluding 
miliary tuberculosis as 24 months, Louis and Boyle on the 
strength of 314 cases said 23 months, Audral 24 months, Sir J. 
Clark (from patients in private practice) 36 months. C. J. B. 
Williams and C. T. Williams (Quain, 1894) give an average 
duration in 198 fatal cases of y\ years, and in 802 living cases of 
8 J years. All these cases had been over a year under observa- 
tion, which necessarily excludes some acute cases ; but with 
4 



50 THE PREVENTION OF TUBERCULOSIS 

this exception they state that these figures " may be taken as a 
correct average for the duration of the disease among the upper 
classes under modern treatment, especially as 72 per cent, of the 
living had recovered sufficiently to pursue their usual avocations, 
and many among them had already lived upwards of 20 years 
since their first attack." 

Walshe (1871) gives the average duration for hospital cases 
in Paris as 23*5 months. He speaks of a case lasting 22 years, 
and of cases frequently lasting from 5 to 10 years. Dettweiler 
gives the average duration of life of the middle-class consumptive 
as 7 years, but Cornet (p. 250) says that the average duration in 
adults cannot be placed higher than 3 years, and in children 
even less. He also quotes Leudet's data, which comprise 48 
cases, among whom the average duration was 5 years for those 
in good circumstances, 3^- years for those in hospitals. All the 
figures show a shorter duration among the poor than among the 
well-to-do. 

If the average duration of phthisis could be worked out 
separately for patients whose illness started at different ages, 
some light would probably be thrown on the varying estimates 
given above. As a general rule, it is a more acute illness in the 
young, and becomes more chronic with advancing years, though 
there are many exceptions to this rule. A further point doubt- 
less has affected the estimates of its duration quoted above. It 
is well known that in the less acute cases the course of the disease 
is not uninterrupted. There are attacks of " bad colds," of 
" influenza," or of pleurisy, or of actually recognised phthisis, 
and then occur intervals in which all symptoms are in abeyance ; 
these intervals shortening if the case progresses. The intervals 
may sometimes extend over many years. Is the duration of 
such cases to be reckoned from the first occurrence of recognis- 
able symptoms to the end of the case ? If so, many months and 
even years in which the patient is apparently well will be in- 
cluded. Until these points are settled, statements as to average 
duration of phthisis should only be accepted when accompanied 
by information as to the intervals during which symptoms were 
in abeyance. 



CHAPTER VI 
THE TUBERCLE BACILLUS 

THE tubercle bacillus (or bacillus of tuberculosis) is a non- 
motile organism, rod-like in shape, with rounded ends. 
Its length is from % to 5 pu {{& = one- thousandth of a milli- 
metre), that is, from one-half to one-third the diameter of a 
red blood corpuscle, whilst its width is about one-sixth of its 
length. When stained with aniline dyes the bacilli often show 
a beaded appearance, which Koch regarded as indicating the 
presence of spores ; but this point is doubtful. We have already 
seen (p. 41) that Koch succeeded in staining the bacilli after 
long soaking of cover-slip preparations in alkaline methylene- 
blue and then using vesuvin as a brown contrast stain. Ehrlich 
soon made known a more certain and more convenient procedure. 
He first stained for fifteen to twenty minutes with an aqueous 
solution of aniline methyl violet or fuchsin, and then decolorised 
with dilute nitric acid, which eliminated the colour from everything 
except the tubercle bacilli. Other methods have been since 
devised, of which the following is the most convenient, especially 
for the examination of suspected sputum. 

The Ziehl-Nielsen Method of Staining. — A small solid 
bit of sputum is taken, spread on a clean cover-glass and allowed 
to become dry. The cover-slip, held in a forceps, is then passed 
three times through the flame of a spirit lamp, holding the sputum- 
spread side uppermost. This fixes the film. A watch-glass is 
partially filled with a solution composed of fuchsin 1 part, absolute 
alcohol 10 parts, and carbolic acid (5 per cent, aqueous solution) 
100 parts. The cover-slip is placed film downwards on this 
solution, which is heated until it steams slightly. The cover-slip 
after three to five minutes is removed, the excess of dye washed 
off with water, and the slip then dipped in a 1 in 4 solution of 
sulphuric acid. As soon as all visible colour has disappeared from 
the film, it is rinsed with several portions of a 60 to 70 per cent. 



52 THE PREVENTION OF TUBERCULOSIS 

alcohol, and finally with water. The film is then counter-stained 
with a i per cent, aqueous solution of methylene-blue. On 
miscroscopic examination the specimen thus prepared shows the 
red bacilli on a blue background. 

The above staining reaction is almost specific for the tubercle 
bacillus, since the leprosy bacillus and the few others which act 
somewhat similarly in resisting the decolorising effect of acids 
are very rarely found under circumstances in which confusion 
would be likely to arise. When bacilli in human expectoration 
answer to the above test it is practically certain that the ex- 
pectoration is derived from a tuberculous patient. 

It must be remembered that negative results from single 
examinations of suspected sputum carry little weight. Three 
specimens at least should be mounted from each sputum, and in 
each of these a large field, spread over the slide in preference 
to the cover-slip, should be examined before a negative certificate 
is given. 

Biology of the Tubercle Bacillus. — For more complete 
study of the biological relations of the tubercle bacillus it is 
necessary to cultivate it on or in artificial media in the laboratory. 
Koch ascertained that it would not grow on the ordinary labora- 
tory media, gelatine, agar, etc., because these did not remain 
unaltered at the body temperature. He finally hit on coagulated 
blood serum as a suitable medium, because it remained solid 
and moist at the body temperature. Having obtained tuber- 
culous material from newly killed animals suffering from recent 
tuberculosis, he successfully grew tubercle bacilli by rubbing 
this material thoroughly on the blood serum by means of a 
platinum loop, and then placing in an incubator at blood heat 
(37° Cr). After the fifth day dull white specks appeared on the 
surface of the serum, and these gradually increased in size, pro- 
ducing small dry scales, which subsequently became confluent, 
forming a greyish-white covering to the serum, the latter not 
being penetrated or liquefied. He subsequently succeeded in 
obtaining similar growths from the cavities of tuberculous lungs, 
from lupus, etc. From observations on such cultures, and on 
cultures in glycerine bouillon agar, have been deduced certain 
facts as to the persistence of the life of the tubercle bacillus 
which have important bearings on the prevention of tuberculosis. 

Range of Temperature.— The tubercle bacillus of mam- 



THE TUBERCLE BACILLUS 53 

malian tuberculosis ceases to grow below 29 C. and over 42 C, 
of avian tuberculosis below 25 C. and over 45 C. The best 
temperature for the growth of the mammalian tubercle bacillus 
is 37°-38° C. As these temperatures are not common in the 
external world, it is important to note that, as Cornet (p. 42) 
remarks, the tubercle bacillus does not meet with the conditions 
of growth " except solely and exclusively within the animal 
organism with its constant and equable temperature of 37°-39° C." 
Or as Dr. Moxon (1885) put it : " The life of the bacillar parasite 
is difficult, easily discouraged by unfavourable circumstance, 
like an aphis by an eastern wind." Beevor, Delepine, and 
Kanthack have succeeded in obtaining growths of the tubercle 
bacillus on potato at room temperature ; but this is difficult, 
and there is no evidence that it occurs frequently. Extreme 
cold does not kill the bacillus. There is considerable discrepancy 
in the evidence as to the thermal death-point of the tubercle 
bacillus. Probably different strains of bacilli vary in this respect, 
and much will depend on the medium surrounding them. Further 
details on this point will be found on page 409. Generally the 
tubercle bacillus is destroyed after 4 to 6 hours' exposure to a 
temperature of 55 C. ; after 15 minutes at 65 C. ; after 5 
minutes at 8o° C. ; after 2 minutes at 90 C. ; and in a less time 
at the temperature of boiling water. In a dried condition its 
vitality may survive higher temperatures than the above. 

The resistance to desiccation shown by the tubercle 
bacillus is its most significant biological feature. It appears to 
owe this resistance to the fact that it contains more fat than 
other bacilli. Koch found that phthisical expectoration which had 
been allowed to dry and been kept at room temperature for five 
to eight weeks was still virulent at the end of the time. S chill 
and Fischer found dried expectoration still virulent on the 
95th day, dead on the 179th da}'\ Toma found dried expectora- 
tion virulent up to ten months (Cornet, p. 43). The duration of 
vitality is much less when the tubercle bacilli are exposed to 
sunlight. Koch found that in direct sunlight they died after 
an exposure varying from a few minutes to several hours, accord- 
ing to the thickness of the layer exposed. Diffuse light has the 
same effect after an appreciably longer time. Strauss found 
that flourishing cultures of mammalian tubercle bacilli perished 
completely on exposure for two hours to the rays of the summer 



54 THE PREVENTION OF TUBERCULOSIS 

sun, while cultures dried in thin smears on glass plates had lost 
their virulence under similar conditions in half an hour. More 
recently Mitchell and Crouch (quoted by Lartigau, p. 29) from a 
study of the influence of sunlight on tuberculous expectoration at 
Denver concluded that the tubercle bacillus as expectorated on 
a sandy soil is still virulent after thirty-five hours' exposure to 
the direct rays of the sun, the virulence becoming lost soon 
afterwards. 

Where there is no free access of air or sunlight the retention 
of virulence in deposited tubercle bacilli has been observed at 
the end of 130 days by Ransome and of 184 days by Fischer. 
It may be added that Cadeac and Malet have produced positive 
results by inoculation of material from tuberculous lungs which 
had previously been buried for 167 days. 

It must be noted that the fact that a tubercle bacillus takes and 
retains the specific stain, does not prove it to be alive. A bacillus 
heated to the temperature of boiling water will take the stain 
equally well. This remark is important in view of the enormous 
numbers of tubercle bacilli daily expectorated by consumptives 
(p. 104). It is probable that the majority of them are non- 
virulent, though in phthisis generally the infectivity probably 
is proportional to the total number of bacilli discharged. The 
infectivity although great must not be exaggerated. The 
tubercle bacillus grows with exceptional slowness both inside 
and outside the body. It has a feeble vitality under both con- 
ditions, and is easily rebuffed. The one circumstance under 
which the extra-corporeal life of the bacillus is prolonged is 
desiccation in places not exposed to sunshine. Such dry ex- 
pectoration will contain numerous living bacilli. 



CHAPTER VII 

INFECTIVITY OF TUBERCULOSIS: A. HISTORY OF 
VIEWS HELD 

THE belief in the infectivity of phthisis is as old as any 
extant account of the disease. Hippocrates said that 
it was of all diseases the most dangerous, and fatal to 
the greatest number of mankind. Galen believes it to be 
dangerous to pass a single day in the company of a consumptive. 
Avicenna the Arabian (a.d. 1037) referred to diseases which are 
" taken from man to man like phthisis." Ballonius, a physician 
of large practice in Paris in the fifteenth century, noted the fre- 
quent occurrence of phthisis in those who tended consumptives. 
Both Morgagni and his teacher Valsalva (seventeenth century) 
asserted that they objected to conduct autopsies on con- 
sumptives on account of the danger of infection. In Italy 
the belief in the infectiousness of phthisis took practical form 
in legislative enactments. In 1746, Ferdinand vi. issued to 
the medical men in charge of the various districts an instruction 
which ran as follows : — 

Experience having shown how dangerous is the use of linen, furniture, 
and articles which have been used by persons afflicted with, or who have 
died of hectic, phthisical, or other contagious diseases, we enjoin on all 
physicians to give notice of those persons who are sick with or who have 
died of phthisis, so that the Alcade may cause the linen, clothing, furniture, 
and other objects used personally by the patient, or which have been in 
his department, to be burned ; so that the Alcade may also order the 
apartment in which the patient died to be replastered and whitewashed, 
and the flooring or flagging of the room or alcove in which the patient's 
bed was placed to be changed. Besides, a registration must be kept of 
places from which clothing found in the shops of second-hand clothes 
dealers comes, with information as to the names and residences of the 
vendors, as well as the persons who have used the linen and garments, 
and dealers in old clothes ordinarily doing business in infected clothes. 
The Alcade shall issue a paper attesting that the said goods are free from 
contagion; this paper shall be the sole authorisation by which dealers 



56 THE PREVENTION OF TUBERCULOSIS 

in second-hand goods will be allowed to keep or sell such goods. Any 
physician who will not give notice of consumptive patients, or those who 
have died of consumption, to the Alcade of his quarter, shall incur, for 
the first offence, a fine of 200 ducats and suspension from the practice 
of his profession for one year ; and for repetition of the offence a fine 
of 400 ducats and the punishment of exile for four years. All other 
persons (infirmarians, domestics, attendants on the sick) who will not 
report the case shall incur a penalty of thirty days in prison for the first 
offence, and four years in the galleys for the second offence. Civil, re- 
ligious, and military authorities shall cause to be burned in civil and 
military hospitals all linen which shall have been used by phthisical 
civilians or soldiers. 

In 1754 the members of the College of Physicians of Florence 
pronounced themselves as on the whole favouring the conclusion 
that phthisis is communicable. In 1782 the city of Naples, 
warned of the infectivity of phthisis by the Medical College 
of its University, enforced a law for the isolation of consumptives 
and the disinfection of their homes and belongings. 

Nor were such views confined to Italy. In a letter to the 
Lancet by Dr. Stretton (December 17, 1898), the following 
quotation is given from a book written by Gideon Harvey, M.D., 
about 1660, in which consumption is described as an endemic 
and epidemic disease : — 

And considering withal its malignity and contagious nature, it may 
be numbered among the worst Epidemicks or popular diseases, since next 
to the Plague, Pox, and Leprosie, it yields to none in point of contagion ; 
for it's no rare observation here in England, to see a fresh coloured lusty 
young man yoake to a consumptive female, and him soon after attending 
her to the grave. Moreover nothing we find taints sound lungs sooner, than 
inspiring or drawing in the breath of putrid ulcered consumptive lungs ; 
many having fallen into consumptions, only by smelling the breath or 
spittle of Consumptives, others by drinking after them ; and what is 
more, by wearing the Cloaths of Consumptives, though two years after 
they were left off. 

In The Expedition of Humphry Clinker, written by Smollett 
in 1771, the same notion of infectiousness finds laughable ex- 
pression. Writing from a fashionable inland health-resort, 
he says : — 

I wish I had not come from Brambletonhall, after having lived in 
solitude so long. I cannot bear the hurry and impertinence of the multi- 
tude ; besides, everything is sophisticated in these crowded places. 
Snares are laid for our lives in everything we eat or drink ; the very air 
we breathe is loaded with contagion. We cannot even sleep, without 



INFECTIVITY OF TUBERCULOSIS 57 

risk of infection. I say, infection. This place is the rendezvous of the 
diseased. You won't deny, that many diseases are infectious ; even the 
consumption itself is highly infectious. When a person dies of it in 
Italy, the bed and bedding are destroyed ; the other furniture is exposed 
to the weather, and the apartment whitewashed before it is occupied 
by any other living soul. You'll allow, that nothing receives infection 
sooner, or retains it longer, than blankets, feather-beds, and mattresses — 
'Sdeath ! how do I know what miserable objects have been stewing in 
the bed where I now he ? I wonder, Dick, you did not put me in mind 
of sending for my own mattresses j but, if I had not been an ass, I should 
not have needed a remembrancer. There is always some plaguy reflec- 
tion that rises up in judgment against me, and ruffles my spirits; there- 
fore let us change the subject. 

The experience of George Sand is also interesting. In 1839 
she wrote from Spain as follows concerning Chopin, her 
travelling companion, who was already consumptive, although 
he did not die until ten years later : — 

Poor Chopin, who had a cough since leaving Paris, became very ill. 
I called in a doctor — two doctors — three doctors, each more stupid than 
the other, and soon it was spread abroad that he was in the last stage 
of consumption. There was great alarm, phthisis being rare in these 
climates, and regarded as contagious. We were regarded as pest-breeders ; 
and furthermore as heathens, as we did not go to Mass. The owner of 
the small house which we had rented turned us brutally out of doors, 
threatening furthermore to bring an action against us compelling us to 
limewash his house, which he said we had infected. We were plucked by 
the law like chickens. 

At Barcelona later on the landlord demanded to be paid for 
the bed on which Chopin had slept. 

Medical men gradually tended towards the opinion that 
tuberculosis was non-infectious, and began to explain it as a 
manifestation of a special constitution or diathesis, while public 
opinion in many countries still regarded it as infectious, this 
belief being carried in some instances to foolish extremes. The 
histories of cholera and influenza present similar anomalies. 
Thus the Royal College of Physicians of London in 1854 reported 
that " the theory that cholera is propagated and diffused by 
means of human intercourse, receives no support from the facts 
relating to variations in the intensity of cholera epidemics, 
and the circumstances determining these variations." In 
another part of their report they quoted the extraordinary 
rapidity of the increase of cholera in a town as "an additional 
reason for believing that the diffusion of cholera in a town is 



58 THE PREVENTION OF TUBERCULOSIS 

independent of contagion." In the same report they record 
their impression that " the share borne by human intercourse 
in the dissemination of the disease is larger " than the statis- 
tical facts seem to indicate. A joint inquiry was made by the 
Provincial Medical Association of England into the contagious- 
ness of influenza in the epidemic of 1836-37, the medical answers 
to the questions on this point being "of an almost uniform 
tenour, the opinion of nearly all those who had the most ex- 
tensive opportunities of investigating the disease, and the best 
means of arriving at a definite conclusion, being that there is 
no proof of the existence of any contagious principle by which 
it was propagated from one individual to another." 

And yet more exact information and more accurate medical 
investigations have proved that infection is the sole means 
for the spread of these two diseases. Tuberculosis differs from 
them in infectivity chiefly in its longer latency and more pro- 
tracted course. 



CHAPTER VIII 

INFECTIVITY OF TUBERCULOSIS : B. EXPERIMENTAL 

EVIDENCE 

INFECTION , by Inoculation. — Villemin's experiments 
(p. 38) gave the first positive evidence of infectivity. 
Previous conclusions to this effect were of the nature of 
surmises, and naturally liable to exaggeration and misconception. 
Villemin's experiments undoubtedly did much to popularise 
the idea that tuberculosis is an infectious disease. Koch's 
experiments demonstrated this fact, and placed Villemin's 
induction on a solid foundation. 

Koch's experiments may be briefly summarised, as they 
illustrate admirably the process used to prove the causal 
relation between a given microbe and the specific disease caused 
by it. 

(1) He took as seed material the tuberculous lymphatic 
glands from freshly killed guinea-pigs which had been inoculated 
about three or four weeks previously with tuberculous material. 
(2) This material was smeared on blood serum and incubated 
at 37 C. until a sufficient growth of tubercle bacilli had slowly 
occurred. (3) From this test-tube cultivation other tubes of 
blood serum were similarly smeared, by rubbing some of the 
small scales from the first tube over the serum in them. Koch 
cultivated the tubercle bacilli in test tubes in this way through 
as many as seventy generations. (4) The inoculation of guinea- 
pigs and other susceptible animals with such cultures was 
followed by the appearance of tuberculous nodules and other 
lesions identical with those found in the animals which pro- 
duced the original tuberculous material. (5) Tubercle bacilli 
were found in these experimentally produced lesions as in the 
original lesions of the first animals, and these tubercle bacilli 
showed the same cultural characters, and when inoculated 

into animals produced similar lesions to those of the original 

59 



60 THE PREVENTION OF TUBERCULOSIS 

disease. Similar experiments made with tuberculous expectora- 
tion from human consumptives, and with tuberculous meat 
and milk, gave the same results. The proof is rendered complete 
by the further fact that tubercle bacilli are not found in any 
diseased conditions other than tuberculosis. 

This is a convenient point to revert to the instances in 
which apparently tubercles had been experimentally produced 
by non-specific inoculation (p. 39). Klebs suggested that ex- 
traneous infection was the cause of these anomalous results, 
and Frankel and Cohnheim showed that this was the correct 
explanation. Watson Cheyne (1883) proved the same thing 
by a series of carefully checked experiments on rodents. 
Wilson Fox in 1867-68 had apparently produced tuberculosis in 
twenty-three out of 117 animals inoculated with such materials as 
pus, putrid muscle, seton, etc., which were supposed to be non- 
tuberculous. At his suggestion the experiments were repeated 
some years later by Dawson Williams, under conditions which 
prevented the occurrence of external infection, and in each case 
a negative result was now obtained. 

The evidence that tuberculosis is infective is not confined 
to experimental inoculation. Were it so, it might still be reason- 
ably contended that tuberculosis is only communicable like 
tetanus or hydrophobia by introduction of the infective material 
(contagium) under the skin. Experimental observations, how- 
ever, have proved that it can be spread either by the inhalation 
or the ingestion (swallowing) of tuberculous material. 

Infection by Inhalation. — Tuberculosis has frequently 
been induced in guinea-pigs by making them breathe in an 
atmosphere containing dust contaminated by tubercle bacilli. 
The lungs in such animals become tuberculous in two or three 
weeks, the extent of the lesions depending on the duration of 
life before the animal is killed or dies. The lungs present the 
same appearances of caseous pneumonia as do the lungs of man 
in ordinary phthisis. The liver and spleen of the infected 
animals also become tuberculous, and the bronchial glands 
appear to be affected as soon as the lungs. 

Infection by Ingestion. — Experimental tuberculosis of 
the intestine has been produced in guinea-pigs, rabbits, dogs, 
cats, calves, sheep, monkeys, etc., by feeding them with tuber- 
culous material. Pigs are readily susceptible to such infection, 



INFECTIVITY OF TUBERCULOSIS 61 

and frequently become infected through being fed on skimmed 
milk derived from tuberculous cows. In these cases the small 
lymphatic follicles in the wall of the intestine are commonly 
infected first, followed about four weeks later by the mesenteric 
and csecal glands. Out of twenty animals examined after experi- 
mental feeding with tuberculous material Sidney Martin found 
the small intestine to be involved in all but one, and the 
caecum in all but three. Intestinal lesions may be absent, 
especially when the dose of infection is small ; and in this 
case the first lesions are in the lymphatic glands. From the 
mesenteric and cascal glands the infection passes to the cceliac 
glands, the liver and spleen, the bronchial and posterior medias- 
tinal glands, and the lungs. Baumgarten, Fisher, and others 
have shown that tubercle bacilli can pass through the mucous 
membrane of the intestine without producing any local ulcer. 



CHAPTER IX 

INFECTIVITY OF TUBERCULOSIS : C. STATISTICAL 
AND CLINICAL EVIDENCE 

ON the strength of the statements given on pp. 8 and 49, it 
has been assumed by some that phthisis is so common 
and so often a non-fatal disease that everyone is more 
or less exposed to infection, and that consequently infection 
can play only a very minor part in its causation. The evidence 
as to the percentage of the total population (say roughly one in 
every two) showing evidence of old tuberculous lesions is derived 
from hospital practice. Persons belonging to this type possibly 
form a majority of the total population, and although the pro- 
portion probably is smaller in other grades of life, we may assume 
for present purposes that the same proportion holds good for 
the general population in England and Wales. But it by no 
means follows that one-half of the total population at any 
given time is actively tuberculous and discharging tuberculous 
material. The fact that recovery has occurred and the patients 
have died from other diseases or from accident, shows the absurd- 
ity of such an assumption. It is highly probable that the vast 
majority of those showing post-mortem these healed lesions 
were " closed " cases, in which the micro-organisms could not 
escape ; so that the patients were not infective even during a 
few months of their life. Further light is thrown on the point 
by a comparison between the deaths from phthisis and the popu- 
lation at each five- or ten-yearly period of life. In Table XVIII. 
the deaths from phthisis have been multiplied by three, on the 
commonly accepted supposition that for each death from phthisis 
during a given year, three other patients have been constantly 
ill with the same disease. On this basis it will be seen that the 
proportion of consumptives in the general population is 1 for 
every 263 persons, varying from 1 in 1881 at ages 5-10 to 1 in 141 

at ages 35-45. At the working years of life, 20-65, on the same 

62 



INFECTIVITY OF TUBERCULOSIS 



63 



assumption it is 1 in 168. Probably the number actually 
phthisical at any given time exceeds this proportion ; but it is 
equally probable that the number at any given time capable of 
imparting infection is not greater than these figures would 

Table XVIII 









On the Assumption that 




Population 


Deaths from 


each Annual Death from 




of England 


Pulmonary 


Phthisis means the Presence 


At Ages — 


and Wales 


Phthisis 


of three Consumptives in 


at the 


in England 


the Population, the 




Census 


and Wales 


Proportion of Consumptives 




1 901. 


in 1 901. 


in the General Population 
at each Age-period was — 


Under 5 . 


3,716,708 


1,171 


1 in 1006 


5-io 








3,487,291 


623 


i „ 1881 


10-15 








3,341,740 


987 


1 ,, 1129 


15-20 








3,246,143 


2,917 


1 » 371 


20-25 








3,120,922 


4,590 


1 „ 227 


25-35 








5,255,840 


9,922 


I „ 177 


35-45 








3,996,005 


9,451 


1 „ 141 


45-55 








2,902,191 


6,653 


1 „ 145 


55-65 








1,943,250 


3,459 


1 „ 187 


65-75 








1,076,006 


1,260 


1 „ 285 


75 and upwards 


441,747 


193 


1 ,, 763 


Total— A 


11 Ag 


es 




32,527,843 


41,226 


1 in 263 



Note. — The above proportions are based on an average duration of 
three years for each case of phthisis. On page 360 I have assumed an 
average duration of ten years, which would include also a large number 
of cases that are never fatal. These estimates must be carefully distin- 
guished from the estimated numbers discussed on page 15, which are 
concerned with ascertaining in a life-table population traced to death, 
how many total consumptives there are. 

lead one to suppose. On this point the considerations detailed 
in Chapter XIII., and particularly on page 101 need to be borne 
in mind. 

Clinical Evidence of Infectivity. — Underlying all in- 
vestigations of the history of individual cases for evidence of 
infectivity are certain fundamental data, which may conveniently 
be summarised here : — 

1. Tuberculosis is due to a specific bacillus. 

2. Tuberculosis has been produced experimentally in animals 
by the introduction of this bacillus, in inspired air or with food. 



6 4 



THE PREVENTION OF TUBERCULOSIS 



3. Man is subject, e.g. in infected households and workshops, 
to the conditions which have been proved experimentally to 
produce tuberculosis in animals. 

It is in the light of these general considerations that the 
following instances of probable infection are to be judged. 
They are given as typical of the form of reasoning which in the 
light of wider investigations is now known to be applicable to 
such cases, and of the kind of evidence which without such wider 
investigation could not be regarded as possessing great weight. 

All the following cases have been taken from local investiga- 
tions of notified cases. 

Case i. — Domestic infection. Father to son 

C. P., aet. 25, admitted to sanatorium October 5, died 
November 22, 1906, of acute phthisis. Was unmarried, and 
lived with his parents up to the time of his illness. His mother, 
two sisters, and a brother are alive and well. No tuberculosis 
known in the family except the father. 



Domestic Influences. 


Age. 


Year. 


Extra-domestic Influences. 







1881 






14 


1895 


Worked as a labourer, "odd 
jobs," up to 19. 


Probably father was ill from this 


19 


1900 


Has worked as a general lab- 


date. 






ourer, generally in the shops 
of the railway works. 


In June 1903, father died, set. 41, 


22 


1903 




death being returned as due 








to " pulmonary and laryngeal 








tuberculosis, 15 months." 








C. P. says he had no cough until 


25 


1906 




a few weeks before admission 








to sanatorium. 









Comments on Case I. — There was protracted infection from 
the father ; also possible industrial infection, but this would 
be only casual. A latent period of at least three years occurred 
between his father's death and his first symptoms. 

Case 2. — Domestic infection. Father to son, or brothers to brother. 
Action of auxiliary influences 

W. O., admitted to sanatorium September 18, discharged 



INFECTIVITY OF TUBERCULOSIS 



65 



October 25, 1906; had advanced tuberculosis both lungs. Had 
cough, for four years before admission. Four sisters and one 
brother have escaped tuberculosis. 



Domestic Influences. 


Age. 


Year. 


Extra-domestic Influences. 







1871 




Mother died of phthisis 


J 3 


1884 






H 


1885 


Apprenticed as a gasfitter. 


Brother died of phthisis, set. 22, 


19 


1890 




in Brompton Hospital ; had 








previously lived at home. 








Another brother died of phthisis, 


21 


1892 




get. 27, at W. Until a few- 








months previously had lived 








with present patient. Domestic 








infection ceased in 1892. 










28-31 


1 899- 1 902 


Served in the Boer War. Had 
enteric fever. Began to 
cough while in South Africa. 


Lived in lodgings after returning 


33 


1904 


Had pleurisy, and was aspir- 


from South Africa. 






ated. 




33-35 


1904-06 


Gasfitter. 



Comments on Case 2. — In my opinion the protracted domestic 
infection which ceased nine to ten years before he began to cough 
caused this patient's tuberculosis, the sickness, exposure, and 
privations of the Boer War serving to light up latent trouble. 
The alternative is that more recent infection in South Africa 
caused his illness. 

The same question of domestic or industrial infection is raised 
in Case 3. 



Case 3. — Domestic injection from brothers and sisters 

A. G., aet. 32, admitted to sanatorium August 1, discharged 
September 12, 1906. The main facts are set forth in the scheme 
on next page. 

Comments on Case 3. — The patient's father and mother are 
alive and well, and there is no family history of phthisis in past 
generations or among uncles or aunts. The patient has been 
exposed to home infection from childhood until he was 15 years 
old. His first symptoms of phthisis occurred ten years later. 
Several possibilities of casual extra-domestic infection present 
5 



66 



THE PREVENTION OF TUBERCULOSIS 



themselves — (i) when a railway shunter ; (2) when a black- 
smith. His work at a music hall was after frequent cough had 



Domestic Influences. 



Excepting the years 1897- 1902, 
has lived at home and been ex- 
posed to the following chances 
of acquiring tuberculosis : — 

One brother, set. 19, died at home 
of phthisis. 

One sister, set. 21, died at home of 
phthisis. 

One sister, set. 5, died at home of 
"congestion of lungs." 



A sister, set. 21, died in an asylum 
of phthisis, 3 years after leaving 
home. 

Patient left home and went into 
lodgings for 5 years. 

Began to have a slight cough from 
this time. 

Patient returned home. No known 
domestic infection from 1890 
(the date sister left for an 
asylum) up to 1906. 

A brother, set. 42 (married, with 
4 children), attended Brompton 
Hospital for a few months with 
one lung affected. No chance 
of infection between the two 
brothers. 

In July> severe hemoptysis . 



Age. Year, 



5 
7 
8 

13 

15 

17 

19 

23 
26 
28 



32 



1874 

1879 
1881 
1882 
1887 
1889 

1891 
i893 

1897 
1900 
1902 

1904 



.906 



Extra-domestic Influences. 



Left school. 

In an auctioneer's office. 



A railway porter in E. (shunting 
and lamps — did not clean out 
carriages). 

Has worked during these ten 
years as a striker and black- 
smith in the railway works. 



Worked as an attendant at 

music hall. 
Is somewhat alcoholic. 



occurred, and probably the same remark applies to his alcoholic 
habits. 



Case 4. — Protracted domestic infection from parents and brothers 

and sisters 

Florence S., set. 24, admitted to sanatorium September 3, 
discharged November 24, 1906 ; early phthisis, with tuberculous 
cervical glands. 



INFECTIVITY OF TUBERCULOSIS 

The main facts are set forth below. 



6 7 



Domestic Influences. 



Has been exposed to domestic 
infection probably from early 
childhood. 

Father, a waiter, died, set. 45, of 
phthisis. 



set. 



15, died of 



A brother, 
phthisis. 

A sister died of phthisis 

Mother died, set. 48, of phthisis . 

First noticed enlarged cervical 
glands. Axillary glands soon 
afterwards inflajned, and sup- 
purated for two years, 

A brother died, aet. 28, of phthisis . 

A brother, set. 34, died of 
phthisis. 

A sister, then aged 27, was 
notified as phthisis in June 
1903. Tub. bac. present. Was 
in sanatorium Aug.-Sept. 1903. 
Is now (Dec. 1906) quite well. 

Cough developed a few weeks 
before admission to sana- 
torium. Tub. bac. found. 
Cervical glands still large 
and indurated, axillary glands 
the same. 



Age. 


Year. 





1882 


8 


1890 


i 

! 

11 


1893 


! 12 
16 


1894 
1898 


17 
21 


1899 
1903 


21 


1903 


24 

i 


1906 



Extra-domestic Influences. 



After the father's death in 1890, 
the mother began a small 
laundry, and the patient and 
her two sisters have helped 
in it. The patient is chiefly 
engaged at needlework. 



Comments on Case 4. — The patient can scarcely be said to have 
been free from the possibility of infection during her whole life. 
She showed tuberculous glands at the age of 16, and signs of 
pulmonary disease eight years later. 



Case 5. — Doubtful whether domestic or industrial infection 

operative 

Clara R., set. 29, admitted to sanatorium July 16, discharged 
August 11, 1906. 

Comments on Case 5. — This is a good illustration of a large 
number of cases in which several points are open to doubt. Was 
the patient infected from her mother, the industrial conditions 



68 



THE PREVENTION OF TUBERCULOSIS 



merely breaking down her resistance ? Were the " constant 
colds " only bronchial attacks on which phthisis was eventually 
engrafted by infection from some of the other work-girls ; or, 
as is more likely, did she have phthisis from 18 years of age 
onwards ? If the latter view is taken, two possible sources of 



Domestic Influences. 



Mother died after "breaking a 

blood vessel." 
Patient does not know if the mother 

had a cough previously. 



Age. 



Extra-domestic Influences. 



Began to have "constant colds." 
Father died of "emphysema." 



At Christmas had a bad cough. 
In May 1905 was in bed 5 days, 

and since then always cough 

and expectoration. 
Admitted to sanatorium 3 months 

after tub. bac. were found 

in sputum. 



*5 



21 
22 

24 



25 

27 
2 8 

29 



1877 
1887 



1892 



[895 



1899 



1902 

1904 

I905 



1906 



Patient went as a dressmaker. 
Worked with the firm A. for 
2\ years, with a friend who 
died in 1901 of pulmonary 
tuberculosis, and was delicate 
in 1892, but is doubtful if she 
then had a cough. 

Patient went to firm B. for 3 
years 

Went to firm C. for 4 years. 
Workroom containing 12 girls 
was overcrowded. 

Often visited the bedridden 
consumptive friend mentioned 
above. 

Went to firm D. for 2 years. 
Large workoom here. 

W T ent to a smaller dressmaker's 
place for 9 months ; room 
underground, stuffy and dusty. 

Went to firm F. ; large work- 
room. 



infection are still known, the dressmaker friend or her mother. 
If the mother died of phthisis, I should lean to the view that she 
was the probable source of infection, because domestic exposure 
is generally more intimate and more protracted than occupa- 
tional exposure to infection. 



Case 6. — Domestic infection from a non-relative. Influence of 

industrial fatigue 

Geo. S., aet. 39, admitted to sanatorium with extensive tuber- 
culosis both lungs, September 8, and discharged November 2, 
1906. Father and mother, five brothers, and two sisters all 



INFECTIVITY OF TUBERCULOSIS 



69 



healthy. No tuberculosis known in his or his wife's family 
except that the latter's father died over twenty years ago of 
this disease. The main facts of his illness are summarised below. 



Domestic Influences. 


Age. 


Year. 


Extra-domestic Influences. 







1867 




None. 






Has been a house -painter all 
his working life. 


Married ..... 


20 


1887 




Three children living : two died 








stillborn, one as shown below. 








Has occasionally sublet part of 








his house, but not, so far as he 








or his wife knows, to people 








with bad coughs except as 








shown below. 








Had a man named P. and his 


35-36 


1902-03 




family occupying part of the 








house for about a year. P. 








was then ill with phthisis, and 








died at Easter 1903. 








G. S.'s child died of "consump- 








tion of the bowels " in August 








1903. This child was born 








November 1902, became ill 








when 4 months old ; never 








had diarrhoea. 








Cough began late in this year 


37 


1904 






39 


1906 





No extra-domestic or family source of infection could be 
detected. The facts as to the P. family need to be stated in some 
detail. G. S., his wife, and four children had two rooms for them- 
selves and let off the rest of the house to P. and family, who lived 
here for nine months. The two families were not very friendly, 
but there was a common scullery and w.c. P. was very dirty in 
his habits, and spat about. His spit-cups were often left in the 
scullery. About six weeks after P.'s death, patient and his 
family left this house. It should be added that Mrs. P., her son 
and two daughters were quite well in November 1906. 

Comments on Case 6. — It seems likely that G. S. and his child 
were both infected by P. The escape of the P. family, and of 
the other members of the S. family, does not exclude this ; 
similar experiences of escape are not uncommon in the acute 
infectious diseases. G. S. while living in the same house as P. 
was working very long hours, and it is likely that this made him 
more open to infection. 



70 



THE PREVENTION OF TUBERCULOSIS 



Case 7. — Possible public-house infection 

W. W., set. 42, admitted to sanatorium August 23, discharged 
October 4, 1906. No family history of phthisis. 



Domestic Influences. 



No infection known. 

Father died of asthma, aet. 44 
Married .... 



Had a bad cough at Christmas 
time> which got well again. 

In June severe hemoptysis, which 
recurred on four occasions. 



Age. 


Year. 





1864 


12 
18 
23 


1876 
1882 
1887 


30 


1894 


39 
41 


1903 
1905 


j 42 


1906 



Extra-domestic Influences. 



Began work as an errand boy. 

\ Worked as a butcher's assistant. 
I Daily frequented various public- 
| houses, and has been a free 
toper from this time onwards. 
^ Worked as an outside salesman 
\ at various butchers' shops. 

I Worked in a baker's shop. 



Comments on Case 7. — There is no evidence of family or other 
domestic infection, and none of industrial infection. The public- 
house is the most likely source of infection. 



Case 8. — Possible occupational infection 

W. H., aet. 33, admitted to sanatorium October 3, discharged 
October 31, 1906. There is no family history of tuberculosis. 
Father and mother, three brothers, and three sisters all alive and 
well. Married for seven years ; two children, both well. 



Domestic Influences. 


Age. 




Year. 


Extra-domestic Influences. 


No infection known. 


1873 


No definite infection known. 




19 


1892 


A soldier from 1892- 1904, in 
India and South Africa. 


Married ..... 


26 


1899 






3i 


1904 


On returning from South Africa 
was engaged as a cleaner in 
the P.O. One of chief duties 
is to sweep out the rooms. 


Has had a coiighfor a year, and 
expectoration for about 6 months 


33 


1906 




before admission to sanatorium. 








Never pleurisy or blood-spitting. 









INFECTIVITY OF TUBERCULOSIS 71 

Comments on Case 8. — The patient's present occupation — 
sweeping out public offices — is a possible source of infection, 
but he may have been infected while a soldier or elsewhere. 
The case is one of a class in which a probable statement of 
infection is impracticable. 

General Considerations on the Statistical Study of 
Histories of Infection in Phthisis. — The preceding cases 
illustrate the types of history often obtained in investigating 
cases of phthisis. The difficulties in tracing the source of infec- 
tion in a given case are much greater than in the acute infectious 
diseases. There is an extremely variable period of latency, and 
the symptoms of the initial stages of the disease may pass unre- 
cognised. The study of latency is so important a part of the 
problem that the next chapter is devoted to it ; and all histories 
of infection should be viewed in the light of the facts there set 
out. In view of the great prevalence of the disease, there is the 
further difficulty that the patient probably has been exposed to 
several sources of infection ; and one has to attempt to balance 
quantitatively the probability of these as the active agent in 
producing disease. They may, in fact, have all been co-operating 
in overcoming the patient's powers of resistance. 

For many years past I have carefully investigated the history 
of all cases of phthisis notified in Brighton. From 1902 on- 
wards (p. 341) a large proportion and during the last year over 
half of these patients have been treated in the Borough Sana- 
torium. It has been possible in this way to obtain fuller informa- 
tion as to the patients than would have been otherwise practicable ; 
and this information has convinced me that histories obtained 
at a single interview with phthisical patients cannot be trusted. 
My experience is that the inquiries made at the first interview set 
up trains of thought and recollection, which when followed up 
at a later interview may completely alter the opinion formed at 
the first interrogation. For this reason I have preferred to state 
below a summary of a hundred consecutive sanatorium cases 
investigated very carefully by Dr. H. C. Lecky, at the 
Brighton Sanatorium, in preference to a very much larger 
number, in which less complete information had been obtained. 
These hundred cases had been exhaustively studied, and for that 
reason the results obtained respecting them are stated in some 



72 THE PREVENTION OF TUBERCULOSIS 

detail. The conclusions based on the less completely exhaustive 
investigation of a much larger number of cases coming under 
my observation during a series of years, confirm the view that 
prolonged latency of already existing disease is not so rare as it 
is often supposed to be. 

In the following table a hundred patients, thus fully investi- 
gated, are classified according to the history obtained : — 



Table XIX 



A. Definite limited domestic infection and definite onset 

B. ,, ,, ,, ,, indefinite onset 

C. Possible continuing domestic infection and definite onset 

D. ,, „ extra-domestic infection and definite onset 

E. ,, ,, public-house „ „ „ 

F. ,, ,, domestic ,, indefinite onset 

G. ,, ,, extra-domestic ,, ,, ,, 
H. No exposure known and definite onset 
I. Suspicion of temporary exposure and definite onset . 
J, No exposure known and indefinite onset 
K. Suspicion of temporary exposure and indefinite onset 
L. History incomplete after every effort made . 



No. of 

Patients. 

20 

12 

7 

7 

4 

4 
16 
11 

9 

7 

2 



By limited infection is meant that the exposure to infection 
is known to have ceased at a given date, as, for instance, at the 
death of a consumptive mother. 

The difficulties of classification of histories of infection are 
very great ; and the above headings have been adopted after 
much consideration. Thus it has been necessary to separate 
cases where the date of onset of symptoms could be definitely 
stated from others in which this was dubious ; and to separate 
cases where a definite limit to exposure to infection could be 
stated from others in which exposure may have continued up to 
the date of onset of the patient's illness. 

The table shows that in 32 per cent, of the cases definite 
infection could be traced. In a further 23 per cent, there was a 
possibility of such infection, but the history was not so precise 
as in the previous group. In 25 per cent, of the total cases no 
exposure to infection could be traced. In a further 18 per cent, 
there was suspicion of temporary exposure to infection, but the 
history was defective or indefinite. 

The fact that in 25 per cent, of the cases no source of infection 
could be discovered is instructive. Even though a considerable 
number of these are explained probably by the fact that many 



INFECTIVITY OF TUBERCULOSIS 73 

patients having open tuberculosis are never seen by a doctor 
and do not die of this disease, it appears likely that in an 
uncertain proportion of cases of phthisis, — probably among the 
most susceptible members of the community, — effective infection 
may be received from merely casual sources of infection. 

Statistical Study of Latency. — In Table XIX. out of 100 
total cases 20 had a definite history of infection ceasing at a 
known date, followed after an interval by phthisis in persons 
who had been exposed only, so far as could be ascertained, to 
this limited infection. Of these 20 patients n were men and 
9 women. The duration of latency in these cases was as 
follows : — Under 1 year, 1 ; 1-2 years, 4 ; 2-3 years, o ; 3 years, 1 ; 
5 years, 2 ; 6 years, 1 ; 9 years, 1 ; 10 years, 3 ; 13 years, 1 ; 
15 years, 1 ; 17 years, 1 ; 20 years, 2 ; 22 years, 1 ; 27 years, 1. 

Thus of the 20 cases 6 only appeared to have had a latency of 
less than 5 years ; in 4 the latent period varied from 5 to 10 
years ; and in 10 there was a latency of over 10 years. 

In the same table 12 additional cases are noted in which 
infection ceased at a given date, but the date of onset of phthisis 
in the person exposed to this infection could not be definitely 
ascertained, though always after the cessation of exposure. In 
4 of these the duration of latency could not be stated even 
approximately ; in one it was probably 2 years ; in one, 3 years ; 
in one, 5 years ; in one, 7 years ; in one, 8 years ; in one, 10 
years ; in one, 14 years ; and in one " many years." 

In each of these cases it is possible that more recent casual 
infection, and not the more remote protracted infection, was 
responsible for the tuberculosis. The view I have taken through- 
out is that given one patient in a family the protracted and 
intimate relationships of domestic life are much more likely 
than casual extra-domestic infection to be the chief means of 
spreading tuberculosis ; and that this is so even when the history 
indicates a period of latency of many years. The possibility of 
long latency and the importance of protracted duration of 
exposure in producing efficient infection will be better appre- 
ciated when the next chapter and Chapters XIX. to XXVI. 
have been read. 



CHAPTER X 

LATENCY IN TUBERCULOSIS 

ANALOGY with Acute Infectious Diseases. — Certain 
features characterise all diseases due to the reception 
into the body of specific infective material from with- 
out. They may be illustrated by the case of small-pox. A 
person inhaling the contagion or microbes of this disease, unless 
protected by a previous attack of small-pox or by vaccination, 
goes through the following stages. There is first a period of 
incubation, or latent period, of about twelve days, in which no 
symptoms of disease can be detected. Then occur severe initial 
symptoms which usually consist of vomiting, severe headache 
and backache, with fever, followed seventy-two hours later by the 
characteristic skin eruption. After an illness of several weeks, all 
the symptoms have disappeared, the patient is no longer infectious 
to those coming into contact with him, and if again exposed to 
infection he is himself as a rule immune against further attack. 
That is a typical instance of the course of an infectious disease, 
and such diseases as whooping-cough, measles, scarlet fever, and 
typhoid fever conform more or less to the type. Some acute 
infectious diseases conform less completely to it. Thus in 
diphtheria the immunity conferred by one attack appears to be 
less complete than in the diseases just mentioned, and in erysipelas 
one attack appears to predispose to rather than to protect against 
a second attack. It is not necessary to enter into the possible 
causes of lack of immunity in these instances. In diphtheria, 
and possibly also in erysipelas, it is sometimes associated with 
the persistence in the patient's body of the bacteria causing the 
disease. Thus Gresswell in 1886 brought forward certain facts 
which appeared to show that " diphtheria in certain individuals 
may become a chronic disease, and from time to time enter upon 
an active and infectious phase." I have elsewhere collected 
similar evidence (1904) of cases of diphtheria, and occasionally 



LATENCY IN TUBERCULOSIS 75 

also of scarlet fever, in which the infection persisted for very 
long periods, and subsequently reappeared after intervals of 
considerable length. The analogy between these exceptional 
conditions and tuberculosis is obvious. In both there is per- 
sistence of infection in a more or less latent form, and in both 
a partial failure to secure by one attack immunity from further 
attack. 

Incubation Period or First Period of Latency. — In the 
acute infectious diseases this is usually a fixed and somewhat 
short period, seldom exceeding a few days. In tuberculosis it 
may be a few weeks or many months, or even many years. There 
are not wanting illustrations of similar prolongations of this 
period in other diseases. Thus in pebrine, the silkworm disease 
investigated by Pasteur, the egg when laid contains the germs 
of the disease. These do not increase in number in the winter 
in the eggs, even though the latter are kept at a favourable 
temperature ; but in spring, with the growth and development 
of the egg, the disease again becomes fully established. In 
leprosy, a disease having close affinities to tuberculosis, two to five 
years is given as the common period of incubation, but a case of 
probable latency of forty years is described by Abraham (1896). 
Hydrophobia usually develops, if at all, within six weeks from 
the time of the bite of a rabid dog. It has been known, however, 
to remain latent for eighteen months and possibly for several 
years. 

The following illustrations from my case-book illustrate 
prolonged latency between the last known exposure to infection 
and the occurrence of an attack of pulmonary tuberculosis. In 
speaking of minimum latent periods in these cases, it must be 
understood that every other ascertainable possibility of infection has 
been investigated with negative result, and that so far as could be 
ascertained the patient had only been exposed to the source of 
infection which is detailed, and to those minor casual infections 
(P- 73) to which everybody may be exposed. 

Case 9. — Mrs. E. S., aet. 32, was admitted to the sanatorium 
with phthisis August 13, 1906. She had been exposed to pro- 
tracted infection as shown in the following scheme, having 
nursed her father, mother, and two brothers while they were ill 
and dying with phthisis : — 



7 6 



THE PREVENTION OF TUBERCULOSIS 



Domestic Infection. 


Age. 


Year. 


Extra-domestic Infection. 


The history makes it probable 





1874 




that during the whole of her 








childhood her mother and one 








brother were suffering from 








chronic phthisis. 






No evidence of any obtainable. 


In 1 89 1 patient's brother, aet. 21, 


17 


1891 




and mother, set. 61, died of 








phthisis at home. Both nursed 








by E. S. In the same year 








another brother, aet. 30, died of 








phthisis in another house. He 








also was nursed by this patient. 








Married ..... 


19 


1893 




Patient's father died of phthisis 


20 


1894 




at E. S.'s house. He was very 








ill for a year, and in bed for a 








month before death. 








In Nov. E. S. in bed for a week 


29 


1903 




with "influenza and left 








pleurisy." Some cough ever 








since. 








E. S.'s boy, aged i^ year, died 


30 


1904 




of acute tuberculosis. 








Admitted to sanatorium 


32 


1906 





Comments on Case 9. — First exposure to infection was probably 
in infancy (1874). The last known exposure was twenty years 
later. First symptoms of tuberculosis occurred in 1903. The 
maximum latent period is therefore twenty-nine years, the 
minimum latent period nine years. 



Case 10. — H. E. G., get. 25, was admitted to the sanatorium 
May 28, discharged July 30, 1906. 

During his holidays H. E. G. visited his home, but there were 
no opportunities of protracted infection from the age of 15 to 21, 
when his cough began. Probably the latent period was much 
longer than six years, but possibly it was less. There was no 
family history of tuberculosis on the paternal side ; but the 
mother's two sisters had died of pulmonary tuberculosis, and the 
evidence pointed to her having suffered from the same disease at 
or before the time of her marriage. 

The evidence in the preceding cases is purely circumstantial, 
and when stated in skeleton and apart from a knowledge of the 
intimate detail of each case is relatively unconvincing. The 
conclusion, however, that the majority of such cases are really 



LATENCY IN TUBERCULOSIS 



77 



Domestic Infection. 


Age. 



Year. 


Extra-domestic Infection. 




1881 




Lived at Ba. until 15 years old, 








and there all the following 








cases of tuberculosis occurred. 








Father died of phthisis one year 


14 


1895 




before H. E. G. left home at 








the age of 


15 


1896 


Apprenticed to a draper in 


Probable 


'Brother died of 
phthisis. 


16 


1897 


London. 


mini- 


Mother died of 


17 


1898 




mum^ 


tuberculosis of 








primary 
latent 
period. 


kidney. 
Sister died of tuber- 


18 


1899 


Became a draper's assistant 


culosis of intestine. 






in C. 




21 


1902 


Cough began this year, and in 
consequence he went to sea 
as a ship's steward. 




22 


1903 


Had to give up sea-life, owing 
to an attack of pleurisy. 




23 


1904 


Began to expectorate. 




25 


1906 


Has not been working for the 
last two years. 



cases of, prolonged latency and not of yielding to casual and 
undetected more recent infection, is supported by converging 
lines of evidence, which may next be considered. 

(1) There is pathological and experimental evidence of pro- 
longed latency, primary and secondary, both in tuberculosis and 
in other infective diseases, both in adults and children. 

(2) The clinical occurrence, both in tuberculosis and in other 
infective diseases, of prolonged secondary latency — i.e. of a period 
during which symptoms of diseases previously present are in 
abeyance — confirms the occurrence of a similar latency before 
the first clinical symptoms appear. 

Pathological and Experimental Evidence of Prolonged 
Latency in Tuberculosis. — Attention has already been drawn 
to the frequency with which small tuberculous lesions are found 
post-mortem in those who have died from diseases other than 
tuberculosis (p. 49). Thus Stengel (p. 255) says :— 



The lesion may become encapsulated and so remain for years without 
producing manifest clinical symptoms. This encapsulating membrane 
may subsequently be penetrated and widespread infection occur. Such 
latent tuberculosis is particularly frequent in the post-bronchial glands. 
These are often found diseased in autopsies in which no tuberculosis is 
found elsewhere. In a notable proportion of such cases emulsions of such 



yS THE PREVENTION OF TUBERCULOSIS 

glands produce tuberculosis in guinea-pigs, showing true latent tuberculous 
disease. Such lesions explain sudden miliary tuberculosis, in which no 
primary focus is found during life. 

Cornet (p. 449) says : — 

It has been shown, by means of inoculation tests, that if these (en- 
capsulated) foci contain caseous material, virulent bacilli are always 
present. Only absolutely fibroid scars, as well as thoroughly calcified 
nodules, proved to be sterile (Kurlow, Green). The consumptive may 
be said to sit upon a volcano. Until the capsules have become absolutely 
perfect and impervious barriers, every event which tends to weaken them, 
or to open up the defects in their architecture, may become the occasion 
of a further dissemination of the bacilli, of a Ugh ting up of a fresh attack. 

It should be added that after giving the above evidence of 
continued virulence of tubercle bacilli incarcerated in old caseous 
lesions, Cornet makes the following remarks, which appear to 
be contradictory to his statement quoted above, and, unlike it, 
are not supported by experimental evidence : — 

It seems to me a little far-fetched to attribute a fresh outbreak of 
the disease, after a quiescence of years, to the resurrection of the bacilli 
imprisoned in the old focus, since we know that the life period of the 
bacilli is bounded by certain definite and narrow limits. 

The latter statement is based apparently on the assumption 
that the bacillus will find as great a difficulty in surviving in 
caseous nodules at the body temperature, as it experiences after 
having been expelled with the expectoration. Cornet emphasises 
Kitasato's demonstration that most of the bacilli in the expectora- 
tion are already dead ; but such expectoration is still commonly 
extremely virulent ; and bacilli in the expectoration imply 
destructive changes of tissues carried to a much further point, 
than those manifested in chronic caseous nodules. Cornet asks 
the question (p. 315) : " What biological facts entitle us to 
assume that the bacillus is capable of remaining latent through 
decades, for forty or sixty years, in the human body ? " He 
is answered partially by the preceding quotations, including his 
own statement. Other experimenters have furnished similar 
evidence, which, although not absolutely direct and certain, 
renders very probable the continuance of latency over many years. 
Thus J. K. Fowler has shown that recrudescence of human 
phthisis coincides in certain instances with active changes in the 
old lesions. In one instance the latency had lasted a period of 
forty years. Haemoptysis generally indicates fresh mischief lit 



LATENCY IN TUBERCULOSIS 79 

up in an old focus of disease. It was the association of recent 
general tuberculosis with recurrence of active trouble in an 
old focus which led Buhl to his great generalisation as to the 
origin of general tuberculosis by self-infection (see p. 37). 
Debove and Achard (p. 271) speak of these old foci as "le feu 
qui couve, qui peut s'etendre" under the influence of protracted 
overwork, fatigue, sorrow, or of an acute inflammatory attack. 

In the preceding remarks it has been assumed that naked- 
eye evidence of old disease was to be found in the cases in which 
old foci produced acute tuberculosis. It may be noted, however, 
as having a possible bearing on the problem of latency, that 
lymphatic glands may contain living tubercle bacilli without 
showing naked-eye signs of implication. The duration of life 
of tubercle bacilli under those conditions is unknown. Loomis 
(quoted by H. Walsham, p. 6), on examining thirty cases in which 
there were no signs of old or recent tuberculous lesions, found 
that in eight cases the bronchial glands were infective to rabbits. 

A. Macfadyen and MacConkey (1903) took mesenteric 
glands from the bodies of children who, dying of other diseases 
than tuberculosis, at the autopsies showed no evidence of tuber- 
culosis. From these glands they injected material into guinea- 
pigs, and tuberculosis was produced in 25 per cent, of these. 
How long these bacilli had been in the tissues without producing 
evidence of disease cannot be said, nor can it be said how much 
longer they would have survived had the children lived ; but these 
interesting observations open up the possibility of prolonged 
latency of tubercle bacilli in the absence of naked-eye lesions. 

Tuberculous lesions may have long periods of latency in 
animals, as well as in man. Thus Baumgarten (quoted by 
Washbourne), inoculated tubercle bacilli into the anterior 
chamber of the eye of a rabbit. A tubercle formed ; this was 
arrested and converted into cicatricial tissue under treatment 
by tuberculin. Nine months later the apparently cured tubercle 
started once more into activity. The active phase subsided for 
the second time, and there was apparent healing. A year later 
it again became active and now spread rapidly, general tuber- 
culosis being produced. This instance, in which the bacilli re- 
mained alive during latent periods of nine months and a year, 
was carried out under conditions avoiding the possibility of 
fresh infection from without. 



80 THE PREVENTION OF TUBERCULOSIS 

Miiller (1906) states that he re-tested with tuberculin two 
sets of cows which when calves had been fed with infected milk, 
and which owing to their positive reaction to the first test had been 
fattened ; the interval between the two tests in one set was a 
year, in the other two years. During the interval the cows had 
been isolated. In the first set the whole of the ten cows reacted 
again ; in the second twelve out of fourteen reacted. Other 
cases have been observed where calves which reacted to tuber- 
culin first showed symptoms of tuberculosis i^ to %\ years later. 
In one batch of twenty cows the animals were 4 to 5 years old 
before symptoms appeared. Then they suddenly in quick succes- 
sion became ill and had to be slaughtered. In all of them an 
advanced and apparently very old abdominal tuberculosis was 
found, the lesions being large and showing caseation and ex- 
tensive calcification, with recent tuberculosis of the lungs and 
other organs. Miiller adds : a few other cases of the same kind 
have been observed in which entire years elapsed before the 
symptoms were exhibited, and in which there had been observed 
a tuberculosis of the udder at the critical time. 

Latent Tuberculosis in Children. — Ganghofner of Prague 
(1905) has recorded as follows the results of 1800 autopsies on 
children dying in that city from causes other than tuberculosis, 
and presenting no symptoms of tuberculosis : — 

Out of 460 deaths of children in the 1st year of life 

latent tuberculosis was found in 33= 7*1 per cent. 
,, 536 ,, ,, aged 1-2 ,, ,, ,, 86=16*0 ,, 

» 476 „ „ ,, 2-4 „ ,, „ 117 = 24-5 

„ 271 „ ,, ,, 4-6 „ „ ,, 73 = 26-9 

„ 123 „ „ ,, 6-8 ,, ,, ,, 33 = 26-8 

English statistics give somewhat similar results. It has 
further to be noted that the absence of tuberculous lesions visible 
to the naked eye does not completely prove the absence of tuber- 
culosis. Ganghofner in the paper referred to above gives in- 
oculation experiments proving the presence of latent tuberculosis 
in children in whom ordinary macroscopic and microscopic 
examination had failed to prove its presence, and similar obser- 
vations have been made by others (p. 79). 

Unless it can be shown to be an exceptional event for living 
tubercle bacilli to be present in old tuberculous nodules, the 
facts narrated in this and the preceding paragraph give a prima 



LATENCY IN TUBERCULOSIS 81 

facie case in favour of the view that adult tuberculosis may often 
be due to the recrudescence of the disease established in small 
foci within the body in early life. This view was emphasised by 
Marfan (1905), whose conclusions were that (1) the infant is 
most exposed to tuberculosis at ages 1-6 ; and that (2) in a 
considerable number of cases showing evidence of tuberculosis 
at or after adolescence, the disease has not been caused by recent 
infection, but by an infection acquired in early life and remaining 
latent in the interval. 

The same conclusion is confirmed by the facts relating to pro- 
longed secondary latency as given below. 

Prolonged Secondary Latency in Diseases other than 
Tuberculosis. — There is, as already mentioned, abundant 
evidence that diphtheria bacilli may in exceptional cases persist 
in the throat for months, or rarely even for several years, without 
any evidence of disease, a second attack being then produced 
without any known external re-infection. The clinical evidence 
of this phenomenon in tuberculosis and in diphtheria is strongly 
confirmed by bacteriological evidence concerning other diseases. 
Thus Washbourne (1896) states that the spores of the hay 
bacillus have been found alive in the organs y8 days after sub- 
cutaneous injection. He quotes an instance given by Schafer 
in which diphtheria bacilli persisted in the throat for six months 
after the attack. I have published (1904) instances of diphtheria 
in which infection persisted 102 and 170 days after the patient 
was apparently well, and cases of scarlet fever in which similarly 
persistent infection was shown. 

The typhoid bacillus sometimes persists in the gall bladder, 
the bones, etc., for a long time after an attack of typhoid fever. 
Hinze (quoted by Washbourne) gives a case of a periosteal node 
appearing four months after an attack of typhoid fever ; six 
months later this became an abscess, which when opened and 
cultivations taken from it, showed typhoid bacilli. Buschke 
found living typhoid bacilli in an abscess seven months and 
Chantemesse and Widal fifteen months after an attack of typhoid 
fever. A most remarkable case for this disease is recorded 
by Dudgeon and Gray (1906), in which the discharge from 
a bone sinus three years after the patient's attack of typhoid 
fever gave pure cultures of typhoid bacilli, and appeared to be 
the cause of the same disease in the patient's wife. 
6 



82 



THE PREVENTION OF TUBERCULOSIS 



Syphilis has many points of resemblance to tuberculosis, 
especially in the slow evolution of its phenomena and the long 
intervals during which symptoms are absent. In this disease 
recrudescence of symptoms frequently occurs, when fresh ex- 
ternal infection can be excluded with certainty, after twenty or 
thirty years of freedom from symptoms ; and in such cases it is 
occasionally noted that, as in tuberculosis, recognisable initial 
symptoms may have been entirely absent. 

Clinical Evidence of Prolonged Secondary Latency 
in Tuberculosis. — The following cases are typical of a large 
number in which long intervals elapsed between the first 
attack of tuberculosis and later attacks, and in which, I think, 
there is strong reason for believing that the later attack was 
caused by changes in the old foci of disease, freeing the bacilli 
from their incarceration and disseminating disease to' other 
parts. 



Domestic Infection. 



No exposure to infection known. 



Age. 



Probable 
mini- 
mum 
primary 
1 atent 
period. 



Family removed from 
Ch — m to C — n. 



M. D. was treated for phthisis at 
the Brompton Hospital 6 months 
as an out-patient and 5 months 
as an in-patient. 

^Father killed in an 
accident. 
M. D. married . 
Secondary No cough or expector- 
latent< ation for 33 years, 
period. although delicate. 

Came to Brighton 
Cough and expector- 
ation began again. 
Admitted to sanatorium 



18 

25 

28 



47 
54 



Year. 



1852. 
1861 
1864 



1867 



1869 



1902 
1906 



Extra-domestic Infection. 



M. D.'s schoolmistress at the 
National School fell ill. 

About this year the schoolmistress 
died of phthisis, after being ill 
for 2 to 3 years, during the 
whole of which time M. D. 
saw her nearly every day, sit- 
ting in her room, and generally 
helping her. 



M. D. had no symptoms of 
phthisis for about 4 years after 
the death of the teacher. 



LATENCY IN TUBERCULOSIS 83 

Case ii. — Mrs. M. D., set. 55, was admitted to the sanatorium 
August 20, 1906, with chronic phthisis. Her family history shows 
a complete absence of this disease. Her personal history is 
presented in the scheme on the preceding page. 

Comments on Case n. — The above facts show in this case a 
primaryUatent period of about 4 years, followed by an illness last- 
ing about a year ; and then a secondary latent period of 32 years. 

Case 12. — Mrs. A. W., set. 24, admitted to sanatorium May 12, 
discharged June 9, 1906. Increase of weight from 8 st. 5 J- lb. to 
9 st. 3 lb. Signs of disease at left apex. Has been married 6 
years, and done only domestic work since that time. Has had 
two children, one well, one died aged 3 years of " bronchitis." 
Husband healthy. Patient was a domestic servant before 
marriage, and did not work for any consumptive family. Patient's 
father died of phthisis 2 J years ago after an illness of 4 years. 
Patient and her husband lived with the father until 3 years ago. 
In 1904 she had " influenza," and afterwards was fairly well 
until March of the present year. When aged 14 had (in 1896) 
a gland removed from the left side of the neck, and in 1904 a 
gland was removed from lower down on the same side of the 
neck. 

Comments on Case 12. — If it be assumed that the first tuber- 
culous gland was the focus of infection of the lung, there was a 
secondary latent period of about 10 years. It is possible that 
the father of the patient had infected her more recently. This 
would make the new primary latent period about 2 to 3 years. 

Case 13. — A. B., set. 49, a policeman, was notified on 
September 2, 1905. Tubercle bacilli had been found in his sputum 
on August 31. Had right pleurisy 16 years ago. His cough dates 
from October 1903, and he had some haemoptysis early in 1905. 
He was said by his doctor to have had " bronchial catarrh " in 
October 1904. Had been in the police service 23 years, and 
before that had been a seaman. Is an alcoholic subject. He 
was admitted to the sanatorium September 8, discharged 
October 6, 1905, and died March 26, 1906. 

Comments on Case 13. — If, as is probable, the pleurisy was 
tuberculous, there appears to have been a latent period of 13 
years between it and the subsequent development of cough. 



8 4 



THE PREVENTION OF TUBERCULOSIS 



On this supposition, we must assume an earlier infection to 
which the pleurisy was secondary. The source of infection 
is undetermined. The opportunities of infection both in his 
occupations and in connection with alcoholic indulgence were 
numerous, and the latent period may therefore have been shorter 
than given above, there being numerous infections at frequent 
intervals. 

Case 14. — J. M., aet. 29, admitted to sanatorium March 24, 
discharged April 20, 1906. Has been a house painter for 6 years, 
before that a soldier for 7 years, of which 6 were spent in India. 
Has been married 5 years, but has had no children. His wife 
is healthy. He has had a cough as long as he can remember, 
and he had haemoptysis before going to India. The cough ceased 
while he was in India, but reappeared on his return, and he has 
gradually deteriorated in health. His father died of phthisis 
when he was 10 years old. His brother M. M. was admitted 
to the sanatorium with J. M., having phthisis and renal disease. 
The brother's first symptoms date from about 4 years ago. The 
two brothers have not lived together for 6 years, and then only 
for a short time. 

Comments on Case 14. — The father probably infected both 
these patients more than 19 years ago. In M. M.'s case there 
was an initial latent period of about 15 years. In J. M.'s case 
symptoms of phthisis appeared much earlier ; but an interval 
of 6 years followed, in which all symptoms were in abeyance. 



Domestic Infection. ! Age. 


Year. 


Extra-domestic Infection. 


! 


1885 




None discovered. 




None discovered. 


Was treated in Brixton for disease 7 


1892 




of the right lung, being under 








a doctor for several months. 








Was then sent into the country 






i 


for three months, and has 






been well from that time until 






Easter 1906, when she again 21 


1906 




began to suffer from cough. 








Was sent to Brighton on account 








of this cough ; and when exa- 








mined shortly afterwards, was 1 






found to have a cavity at the 






right apex. 




• 



LATENCY IN TUBERCULOSIS 85 

Case 15. — Jessie R., aet. 21, was admitted to the sanatorium 
July 26, and discharged October 25, 1906. She had disease, 
including cavitation, of the upper part of the right lung. See 
scheme on preceding page. 

Comments on Case 15. — The first attack 14 years ago was 
diagnosed as phthisis. From this date to her present attack, 
the patient had been well. There was no family history of 
tuberculosis, and the patient, who is in fairly good circumstances, 
has not been exposed to any known infection. 



CHAPTER XI 

SOURCES OF INFECTION 

SINCE tuberculosis is an infective disease, its prevention 
evidently must depend upon an accurate knowledge of 
the sources from which infection is derived. With rare 
exceptions, tuberculosis in man has been attributed solely to 
infection derived from other human patients, or to infection 
from food animals, especially cattle or pigs. The possibility 
of infection by animal food-stuffs raises the large question of 
the inter communicability of human and bovine tuberculosis, 
which is discussed in Chapters XVI. to XVIII. Tuberculosis 
from lower animals is only likely to be conveyed to man to any 
considerable extent by the ingestion of infected foods, especially 
milk. From human patients infection may be direct, e.g., in kiss- 
ing or during coughing accompanied by the projection of particles 
of expectoration into another person's mouth or nostrils ; or 
indirect, as when the dried expectoration of a consumptive is 
inhaled. The chief possible means of infection are thus — 
i. The inhalation of dried expectoration. 

2. The inhalation of particles of wet expectoration. 

3. The ingestion of tuberculous milk or other foods. 

Of these three it is agreed by most hygienists that only a 
relatively small part of the total human tuberculosis is due to 
tubercle bacilli of bovine or other animal origin, though opinions 
differ as to the size of this proportion. Very few agree with 
von Behring in considering bovine infection as the sole or 
even the chief source of human tuberculosis. 

Both 1 and 2 named above are concerned with coughing 
and expectoration, which are the main means of tuberculous 
infection. Other discharges from tuberculous patients, as 
from the bowels in tuberculous enteritis, — or even without such 
enteritis, when tuberculous expectoration has been swallowed, 
— from the skin in tuberculous abscesses, by the urine in renal 



SOURCES OF INFECTION 87 

tuberculosis, are doubtless infective, but for fairly obvious 
reasons they seldom have the same opportunities to cause 
infection as the expectoration. 

Expectoration can, as indicated above, spread infection 
in two ways. Either it is inhaled after having become dried 
and powdery, or it is inhaled directly in the form of spray or 
small pellets expelled as the patient coughs. These two chief 
modes of infection are fully considered in Chapter XII. In 
this chapter will be considered briefly certain other modes 
of infection, less important than the inhalation of infective 
dust or spray, but conveniently disposed of at this stage. These 
methods consist in (1) inoculation with tubercle bacilli, (2) in- 
fection by kissing or by other means of conveying infected saliva, 
and (3) infection by contaminated hands or by flies. 

Inoculation with Tuberculous Material. — The sub- 
cutaneous injection of tubercle bacilli in experimental animals 
produces tuberculosis which, following the lymphatic tracts, 
may soon become general. Such a result is rare in ordinary 
life, probably because the dose of infection received through 
cuts or abrasions of the skin is usually small. Lupus, a disease 
eventually causing a disfiguring ulceration of the skin, is a 
local form of tuberculous infection. It rarely occurs in covered 
parts of the skin, and is probably caused by accidental inocula- 
tion of tubercle bacilli. Local tuberculosis has occasionally 
been produced at the seat of local injuries, received, for instance, 
while making autopsies on tuberculous patients. Such cases are 
rare, and the resulting tuberculosis seldom extends beyond the 
next chain of lymphatic glands ; but in a few instances general 
tuberculosis has followed. 

The possibility of inoculation with tuberculosis during 
vaccination with bovine lymph has been asserted. It must 
be regarded as a very remote and almost negligible possibility ; 
and as non-existent, when, — as is always the case in well-regu- 
lated vaccine establishments, — the calves from which the lymph 
has been obtained are killed and minutely examined for tuber- 
culosis, and the lymph never distributed unless complete absence 
of tuberculosis can be certified. 

Infection by Soiled Hands. — Obviously a phthisical 
patient who is not cleanly in his or her habits might easily infect 
hands and fingers during expectoration, and articles of food 



88 THE PREVENTION OF TUBERCULOSIS 

might thus become infected. Baldwin of Saranac Lake (quoted 
by Lartigau, p. 121) examined the hands of fifteen consumptives, 
and of this number ten were found to be contaminated with 
tubercle bacilli. These facts emphasise the importance of 
care in the use of handkerchiefs and spitting-cups, and the 
need for washing the hands after they have become fouled. 
This source of infection must, however, be regarded as of much 
less magnitude than others to be considered subsequently. 

Infection by the Saliva. — Drinking-cups, spoons, etc., used 
in common may be a source of infection, and so likewise may 
kissing, if tubercle bacilli are present in the saliva. On this point 
divergent statements are made, Cornet (Cornet, p. 187) saying 
that the saliva is ordinarily germ free ; while several observers have 
confirmed the frequent presence of tubercle bacilli in the saliva 
(Lartigau, p. 121). Cornet himself (Cornet, p. 166) minimises 
the value of the preceding statement by urging that even if 
the saliva " should contain bacilli, they would be carried into 
the mouth and the digestive tract of the other person, and 
not into the lungs " ; although he says that " with children 
the case is different. Their mucous membranes are far more 
susceptible to the bacteria, and it may be that kissing is not 
infrequently of moment in producing scrofulous cervical glands." 
With his statement that " so far as we are able to judge, this 
danger does not play an important r6le among adults," I am 
inclined to agree. Dosage would probably be small in infection 
by kissing or by drinking-cups, etc., and it is unlikely that a 
serious amount of infection is often produced by this means 
alone. 

Infection by Flies. — It is obvious that flies having fed on 
or having been fouled by tuberculous expectoration might 
contaminate food and thus convey infection. This possibility 
has been proved experimentally. Thus Spillmann and Haus- 
halter (Cornet, p. 82) found tubercle bacilli in the abdominal 
cavity and in the faeces of flies which had sucked at the sputum 
cloths of consumptives. These observations have been confirmed 
by others. In measuring the relative importance of this method 
of spreading infection, it has to be remembered that the faeces 
of flies and the amount of material capable of being carried 
on their limbs are extremely minute as compared with the 
material in a single expectoration.. 



CHAPTER XII 

SOURCES OF INFECTION (Continued)— -DUST AND SPRAY 

VILLEMIN (p. 38) appears to have been the first authority 
to recognise the importance of dried tuberculous expectora- 
tion as a vehicle of infection, most previous writers having 
laid stress on the supposed dangers of direct personal com- 
munication, or even of handling tuberculous corpses (p. 35). 
The deaths from phthisis of Bayle, Laennec, Louis, and several 
other French physicians who practised much among con- 
sumptives, doubtless favoured the view of direct infection from 
consumptive patients. 

Even in recent years the idea that air quietly expired by 
a consumptive may contain tubercle bacilli has been entertained, 
and some experiments by Ransome (1882) and by Williams 
(1883) appeared to confirm it. It is probable, however, that in 
these experiments insufficient precautions were taken to exclude 
the possibility of spray or droplets ejected during coughing 
gaining access to the experimental apparatus. Tyndall has 
supplied the experimental proof that in quiet breathing expired 
air is absolutely sterile. 

For the rest of this chapter it will be assumed that inhaled 
dust can penetrate to the air cells of the lungs. The evidence 
for this statement, and the discussion of the relative share of 
this and other methods of infection will be given in later chapters. 
In this chapter we shall discuss the operation of infection by 
dust and by spray, as far as possible in the historical order of the 
most important experiments that have been made. 

Koch's Experiments and Conclusions. — Koch describes 
his procedure in experiment 26 of his classical paper as follows : — 

A very roomy box, having on one side an opening for the orifice of 
the spray apparatus, was placed in a garden at a good distance from 
any habitation. The spray apparatus was placed outside the box, with 

its orifice projecting into the interior. By means of elastic tubing and 

89 



90 THE PREVENTION OF TUBERCULOSIS 

a suitable length of lead pipe passing through the woodwork of a closed 
window, the apparatus was connected with an indiarubber bellows, and 
so could be worked from the room beyond the region of the spray. 

A pure culture taken from a phthisical lung in the human subject, 
No. i, and carried through twenty- three generations in fifteen months, 
was rubbed up with distilled water, and the fluid diluted to such an ex- 
tent that it looked almost clear. Any visible fragments present in the 
fluid subsided after standing a short time ; the upper layer, which showed 
hardly any opacity, was poured off and used for inhalation. Fifty c.cms. 
were sprayed in the course of half an hour on three successive days, and 
inhaled by the following animals in the box : 8 rabbits, 10 guinea-pigs, 
4 rats, and 4 mice. After the inhalation, the animals were kept in 
separate roomy cages and well looked after. In some of the animals, 
dyspnoea appeared after ten days, and 3 rabbits and 4 guinea-pigs 
died in the course of fourteen to twenty-five days. All the remaining 
animals were killed twenty-eight days after the last inhalation. All the 
rabbits and guinea-pigs had numerous tubercles in the lungs, the size 
of the tubercles being proportionate to the length of time the animals 
had lived after inhalation. 

In this experiment Koch was spraying cultures made from a 
tuberculous lung, but in his comments on it he says : — 

There can likewise be no doubt as to the manner in which the tubercu- 
lous virus is carried from phthisical to healthy subjects. By the force of 
the patient's cough particles of tenacious sputum are dislodged, discharged 
into the air, and so scattered to some extent. Now numerous experi- 
ments have shown that the inhalation of scattered particles of phthisical 
sputum causes tuberculosis with absolute certainty, not only in animals 
easily susceptible to the disease, but in those also which have more power 
of resisting it. It is not to be supposed that man would be an excep- 
tion to this rule, but, on the contrary, we may surmise that any healthy 
person brought into immediate contact with a phthisical patient, and 
inhaling the fragments of fresh sputum discharged into the air, may 
thereby be infected. But probably infection will not often take place in 
this way, because the particles of sputum are not small enough to remain 
suspended in the air for any length of time. Dried sputum, on the 
contrary, is much more likely to cause infection, as, owing to the negligence 
with which the expectoration of phthisical patients is treated, it must 
evidently enter the atmosphere in considerable quantity. The sputum 
is not only ejected directly on the floor, there to dry up, to be pulverised 
and to rise again in the form of dust, but a good deal of it dries on bed-linen, 
articles of clothing, and especially pocket-handkerchiefs — which even 
the cleanliest of patients cannot help soiling with the dangerous infective 
material when wiping the mouth after expectoration — and this, too, is 
subsequently scattered as dust. 

It is evident from this quotation that Koch regarded dried 
sputum as the most fertile source of infection. This view has 



SOURCES OF INFECTION 91 

been confirmed by the experiments of Cornet, Strauss, and many 
others. We must next consider the experiments and views of 
the school of Flugge. 

Flugge's Experiments and Conclusions. — The following 
summary is made from Flugge's well-known paper (1898). He 
quotes results previously obtained by Sticker, who failed to infect 
animals by making them inhale tuberculous sputum mixed with 
fine sand, and showed that the failure was owing to the fact that 
although the conglomerate of sputum and sand was driven into 
the apparatus by a rapid current from bellows used in the experi- 
ment, yet it failed to be inhaled by the feeble inspiratory suction 
of the animal. On the other hand, Cornet succeeded in pro- 
ducing tuberculosis by inhalation in guinea-pigs, by discharging 
the loaded air direct into the animals' mouths, or by holding 
them over a carpet while it was swept, so that the sputum par- 
ticles with which it had been strewn were raised. These experi- 
ments in which the sputum is artificially dried and powdered, 
and the air currents are more rapid than those occurring natur- 
ally in a room, are, according to Flugge, not comparable to normal 
conditions of life. 

The important point to settle is whether under natural 
conditions sputum, as for instance in a handkerchief, ever 
assumes the degree of dryness requisite for the dust to escape 
from it and become the source of infection. Experiments were 
made on this point by Beninde. He showed that weak currents 
of air would not disperse bacteria from handkerchiefs which had 
been deprived of 60 per cent, of their moisture by being kept in 
the pocket for one day. Flugge also states that 

sputum on the floor very rarely is left long enough to reach the neces- 
sary degree of dryness ; each washing of the floor lessens the danger. In 
ordinary dwelling-houses it is next to impossible to find dried sputum 
in the dust, though in workshops, etc., where men may spit on the floor, 
tuberculous dust can quite well become sufficiently dried to be blown 
up into the air. 

He goes on to say that 

sputum is difficult to pulverise finely, and the coarser particles are not 
dangerous. It is true that sweeping and dusting disturb the coarser 
particles, but these do not often reach the respiratory passages, and fall 
so quickly again on to any flat surface, that it is not possible for much to 
be inhaled ; and as the finer particles, capable of suspension for a long 
time, are very rarely and sparsely present, the danger is very slight. 



92 THE PREVENTION OF TUBERCULOSIS 

f Fliigge summarises the results of his experiments in the 
following words : — 

Infection from pulverised dried sputum is doubtless possible, but it 
occurs relatively seldom, because particles fine enough to be conveyed 
readily by air can only be formed from completely dried sputum, and 
then only in very limited quantities. 

In his view that the danger from dried sputum has been 
exaggerated, Fliigge in certain particulars was anticipated by 
Cornet, who, although he is the chief advocate of the view that 
tuberculosis is spread by infective dust, minimises its operation 
in the following words extracted from his first work : — 

Any one who has himself tried to rub well-dried sputum into particles 
and to pulverise it very finely will agree with me that it is no easy task to 
produce a really fine powder which remains suspended in the air for some 
time. The strong statements that have been made up to now — that 
one has only to rub with the foot on the dried sputum to raise immediately 
a cloud of infectious germs — are absolutely false. 

Experimental Evidence of Spray Infection. Heymann. 
— Leaving aside experiments under artificial conditions, we may 
consider those made with the natural spray produced by coughing, 
sneezing, and speaking. Laschtschenko, after washing his mouth 
with broth containing Bacillus ftrodigiosus, was able to recover 
these from agar plates dispersed over a room. Sneezing was 
most efficient in dispersing the bacteria, coughing next most 
efficient. He made consumptives cough on to glass, and from 
four patients he thus obtained abundant tubercle bacilli. 

Heymann (1901) carried this further. He first made experi- 
ments to determine the local dispersion and limitation of the 
sputum drops. A patient was placed for ij hour in an experi- 
mental chamber in which plates were arranged in different 
positions to receive droplets. After the patient had left the 
chamber it was carefully closed and protected from sunlight for 
some hours. The deposits on the plates were then examined by 
inoculation experiments. In the case of a patient who used a 
handkerchief before his mouth when coughing, it was found that 
out of 36 animals inoculated with material from plates taken out 
of the chamber after its use, 11, or 30*5 per cent., were infected ; 
and that of 34 animals inoculated from plates taken out of a 
chamber where the patient did not use a handkerchief, 24, or 
70*5 per cent., were infected, 



SOURCES OF INFECTION 93 

Most of the spray droplets when coughed up by the patient 
were of a size which made them fall directly on to the glass plates 
at short range. Some of the finer droplets, however, were easily 
carried behind the patient by currents of air. 

Six experiments were then made, handkerchiefs being held 
from 5 to 10 cms. (2 to 4 inches) away from the mouth of the 
coughing patients. Nearly half of the animals inoculated from 
plates exposed under these conditions escaped infection. 

The experiments showed that infective particles are rarely 
carried more than 1 metre (39*4 inches) beyond the person 
coughing, so that protection against spray infection is easy to 
secure by keeping a distance of about an arm's length from the 
patient, and by the latter using a handkerchief when coughing or 
sneezing. 

Experiments were also made by Heymann on the duration 
of suspension in air of droplets containing tubercle bacilli. A 
consumptive was made to cough into an experimental chamber 
containing twelve covered plates, the covers of which were then 
by mechanical means removed and replaced at definite intervals. 
By these and other experiments it was proved that the duration 
of suspension in air is not great, and consequently the amount of 
infection thus received — except under conditions of the closest 
intimacy — must be very small. The larger size of many of the 
droplets diminishes the duration of suspension in the air. Hey- 
mann next draws attention to the adhesiveness of such droplets 
as have settled. He says : — 

If these drops are allowed to dry for a short time on acid plates, they 
can be rubbed fairly energetically with rough rags without the drops 
being entirely removed. This fixation would become more definite if 
the drops had settled on a fairly thick layer of dust ; and with the cleaning 
methods, e.g. damp dusters, etc., employed in sickrooms, it is improbable 
that much danger exists of infective particles being again raised into the 
air. 

He then investigated the duration of vitality of tubercle 
bacilli in spray deposited on plates from sputum ejected by an 
artificial spray apparatus and by patients in coughing. In 
all, 96 plates were prepared, and were kept from 12 hours to 
90 days. It was proved that of the tubercle bacilli from the 
natural spray those kept in the dark lost their virulence within 
18 days at the most, and those exposed to the light within 



94 THE PREVENTION OF TUBERCULOSIS 

3 days. The artificially sprayed tubercle bacilli kept in the 
dark were virulent only for 7 days at the most. 

The formation of pulverised sputum and its power of remain- 
ing suspended in the air were next investigated. Experiments 
were made showing that in quiet air after carpet-beating, etc., 
the suspension of bacilli in the air was very short. In moving 
air, dust could not be detected ten minutes after the cessation 
of the beating and brushing. Heymann indicated the defects 
in Cornet's researches on dust infection. The number of experi- 
ments in which droplet infection could be excluded with certainty 
was, according to Heymann, not great ; and Cornet's technique 
allowed of the inhalation of coarser particles and of adherent 
droplets, as well as of the fine dust, which alone would be inhaled 
under natural conditions. Heymann narrates a number of ex- 
periments, in which he claims that these possibilities of error 
were excluded. The number of tests made was 59, and 5 of 
the inoculated animals, or 8*5 per cent., were infected with 
tubercle. Heymann concludes : — 

It is consequently demonstrated that dry dust containing tubercle 
bacilli is only present in slight quantity in rooms of consumptives. The 
low percentage in his results in comparison with Cornet's was striking, 
so that a repetition of the experiments using Cornet's spongelet method 
was thought worth making. 

The adoption of this method of collecting the dust gave 
a greater proportion of positive results, 15*8 per cent, in private 
rooms, and 40*3 per cent, in hospitals. These results showed 
Heymann that infective particles may be transported by contact 
and dust, and deposited at a considerable distance from patients, 
but that, as a rule, they fall and adhere, being generally too 
heavy to be blown about. 

Adding together Heymann's two sets of dust experiments, 
the total results were as follows : — 

Of a total of 239 dust samples obtained from the sickrooms of con- 
sumptives, 44 contained virulent tubercle bacilli (=18-4 per cent.). In 
the 123 obtained from hospital wards, 30 contained the bacilli ( = 24*3 
per cent.). In the 116 from private houses occupied by consumptives 
only 14 (= 12 per cent.) were infective. The hospital incidence w-as greater 
than that in the homes of consumptives, whereas in Cornet's experiments 
the incidence in the two was nearly equal. 

In summing up the conclusions to be derived from his ex- 



SOURCES OF INFECTION 95 

haustive investigation, Heymann is of opinion that spray and 
dust infection are equally important, one form taking pre- 
cedence over the other, according to circumstances. When 
spray infection persists for a considerable time, the patient's 
environment must contain much infective material, but obviously 
it varies with the stage of disease, and has the limitations 
of vitality elsewhere indicated (p. 104). As a rule, infective 
material is not sprayed further than an arm's length. The 
duration of suspension of droplets in the air is limited, but 
they have been found as long as half an hour after the last 
attack of coughing ; droplets floating for so long a time as 
this contain only a few tubercle bacilli. Heymann adds : — 

Under natural conditions droplet infection is only operative in cir- 
cumstances of closest intimacy, in the close intercourse of married people 
and of mother and child ; among attendants on the sick, and in factory- 
rooms, workshops, and offices. 

Tubercle-containing dust particles are produced by the escape of 
sputum droplets, and by remnants of sputum which may adhere to the 
hand, pocket-handkerchief, bed-linen, carpets, and furniture, and especi- 
ally to the floor as the result of spitting. I differ from Cornet in that I do 
not attribute a greater power to this dust than to spray in producing 
infection, because to enable infection to be produced the particles of 
dust should possess an exceedingly fine consistency, enabling them to be 
moved by even slight air currents. This they do not possess. The closely 
adhering dust precipitated in sickrooms was found to contain only a few 
tubercle bacilli ; and it may have settled down there in the course of 
some days, so that these scanty positive results of investigation of the 
dust afford no positive measure of the danger of inhalation of infective 
dust. Under special conditions, in factories and workshops and on rail- 
ways where numbers of human beings crowd together and cause con- 
siderable agitation of the air, fine dust is formed, which may produce 
infection derived from long deposits of phthisical sputum. 

Infection during Speaking. — Fliigge and others, after 
rinsing out their mouths with broth cultures of B. prodigiosus, 
have found that the bacilli could be caught on culture plates 
in different parts of the room, some of the plates which 
were placed behind the speaker giving positive results. It 
would be improper to infer from these experiments that similar 
dissemination of tubercle bacilli occurs when consumptives 
are speaking. As Cornet has said (p. 501) : — 

When Fliigge takes cultures of the prodigiosus into his mouth, 
determines that the germs are distributed in talking and coughing, and 



96 THE PREVENTION OF TUBERCULOSIS 

from this argues that the same occurs in the case of the tubercle bacilli, 
he neglects the most important link in his evidence, the tertium compara- 
tionis, namely, the proof that the saliva of consumptives contains any- 
thing like the same number of germs as when the mouth is filled with 
a culture of prodigiosus. Researches upon this point show that the 
saliva is either free from the bacilli or contains them in rare cases and in 
small numbers. 

. Tubercle bacilli are few in number or absent from the mouth 
of a consumptive except when coughing. Furthermore, the 
viscous expectoration is much less easily scattered than watery 
saliva. 

Cornet's Experiments and Conclusions. — According to 
Cornet (Cornet, p. 98), Tappeiner first showed conclusively that 
infection occurs by means of dust. Tappeiner infected dogs by sub- 
mitting them to the inhalation of powdered tuberculous expec- 
toration. Koch, Cornet, and others repeated these experiments, 
substituting pure cultures of the tubercle bacillus for dried 
expectoration. Other investigators with similar methods failed 
to infect the animals experimented on. Hence Baumgarten 
and more recently Flugge have minimised the importance of 
infection by the inhalation of dried expectoration. Their failures, 
however, in the opinion of Cornet (Cornet, p. 102) were due 
to a technique, faulty in departing from the natural conditions 
governing infection by inhalation. The animals in their experi- 
ments had been placed in closed cages, in the air of which dried 
powdered expectoration was made to circulate by mechanical 
means. But, as pointed out by Cornet, expectoration is very 
hygroscopic, and at once under the above conditions absorbs 
the respiratory moisture, becomes heavy, and is no longer borne 
along in the inspiratory current of air. 

In a series of experiments made in 1898 Cornet set himself 
to imitate experimentally the conditions which would be found 
in the dwelling of an unclean consumptive. In a room contain- 
ing about 99 cubic yards of space he scattered over the carpet 
dried tuberculous expectoration mixed with dust, and placed 
guinea-pigs, some on the floor, and others upon stages 2 to 3 
inches, 16 inches, and 4 feet above the floor. Then the floor 
was swept in the usual way with a stiff broom, so that a dense 
dust was produced. Cornet protected himself by wearing an 
overall coat, and over his face a complete hood with protected 
glass openings. A second group of animals was subjected to 



SOURCES OF INFECTION 97 

direct inhalation of infected dust. Of 48 guinea-pigs used, 
46 became infected. Neisser (Lartigau, p. 130) showed by 
other experiments that mild currents of air can carry tubercle 
bacilli from place to place, and that dried tubercle bacilli can 
be held for some time in the suspended dust of ordinary rooms. 

Cornet (Cornet, p. 502) quotes B. Franker s proof that the 
number of bacilli disseminated by coughing is insignificant as com- 
pared with the number released by the drying of expectoration. 
He let a number of consumptives wear masks for twenty-four 
hours at a time, and with 219 of these masks he caught 2600 
tubercle bacilli in 32 days. Compare with this the 300 million 
bacilli which Heller estimates to be present in a single pellet 
of expectoration. This would mean 7200 million in one day, 
assuming the expectoration to occur only once an hour. Thus 
one consumptive in one day may discharge in expectoration 
7,200,000,000 bacilli ; a number of consumptives in 32 days 
discharged by coughing 2600 bacilli. It does not follow that 
the relative danger from dust and from spray is in the pro- 
portion of these figures ; the proportion of each which, while 
still virulent, reaches the mucous surface of a susceptible person 
has to be considered. There are no means of stating this ; 
it will vary with circumstances. Probably dust infection is 
greater than spray infection in industrial and social life ; dust 
infection bears a smaller proportion to spray infection in domestic 
than in extra-domestic life ; but the evidence does not show with 
certainty that under either set of circumstances spray infection 
operates to a greater extent than dust infection. Whatever 
be the proportion between the two, practical precautions must 
take cognisance of both methods of spread. 

Importance of Dust Infection. — Whatever be the pro- 
portionate share of infective dust and infective spray, it is 
certain that dust plays an important part in spreading tuber- 
culosis. There is abundant evidence that the dust in the 
vicinity of consumptives contains frequently, while that from 
other localities seldom contains, tubercle bacilli. Cornet in 1888 
(Cornet, p. 86) first clearly established these important facts. 
Having carefully excluded the possibility of infection from other 
sources, he inoculated guinea-pigs with the dust obtained from 
the walls and floors of sickrooms occupied by consumptives. 
His results were as follows : — 
7 



98 THE PREVENTION OF TUBERCULOSIS 

In 7 hospitals 38 tests were made, 94 animals being inoculated 
with dust. Of this number 52 died from diseases other than 
tuberculosis, 22 remained healthy, and 20, or 21/3 per cent., 
became tuberculous. In 3 asylums n tests were made, 43 
animals being employed, of whom 16 died from other diseases, 
14 remained healthy, and 13, or 39*4 per cent., became tuber- 
culous. In 2 prisons 5 tests were made on 14 animals, all 
with a negative result as to tuberculosis. In the dwellings 
and workplaces of consumptives 62 tests were made, 170 
animals being employed, of whom 91 died from other diseases, 
45 remained healthy, and 34, or 20 per cent., became tuber- 
culous. In a surgical ward 3 tests were made, 8 animals 
being employed in each instance, with a negative result as 
to tuberculosis. In certain streets 14 tests were made ; 41 
animals were employed, and here again a negative result as 
to tuberculosis was consistently obtained. 

The dust of rooms occupied by consumptives was regularly 
virulent in the instances in which the patient had been in the 
habit of spitting into his handkerchief or on the floor ; it showed 
no evidence of virulence when the spittoon or spit-bottle had 
been regularly used. Cornet also found virulent tubercle 
bacilli in the dust of a room in which a consumptive had died 
six weeks previously. It should be carefully noted that the 
samples of dust were taken by Cornet from places where 
they had settled by gravity from the air, and in which direct 
pollution by tuberculous matter, either coughed up or expec- 
torated, or by means of dirty fingers, cups, cloths, or otherwise, 
was practically impossible. 

Other observers have confirmed these results. Dr. H. Coates' 
researches, carried out under the direction of Professor Delepine 
at Owens' College, are especially valuable. He found that in 
only two out of a large number of film preparations of dust 
prepared by him were tubercle bacilli discoverable. Cultiva- 
tion methods were obviously out of the question, as other 
organisms grow so much more quickly than the tubercle bacilli. 
Cornet's inoculation test was therefore used. Samples of 
dust were collected from situations in which dust had settled 
naturally from the air, and where there would be no likelihood 
of direct contamination with expectoration or by infected 
articles. Samples of dust were taken from each house from the 



SOURCES OF INFECTION 



99 



floor, skirting-boards, walls, shelves, mantelpieces, etc. Three 
classes of houses were examined. 

I. Houses which were in a dirty condition, and in which 
a consumptive patient was living who was taking no precautions 
to dispose of his expectoration so as to prevent infection of 
the atmosphere, but who spat freely on to the floor, or into his 
pocket-handkerchief, etc. 

II. Houses which were in a very clean condition, but in 
which a consumptive patient was living who was not sufficiently 
careful as to the disposal of his expectoration. 

III. Very dirty houses, in which there had been no case of 
tuberculous disease for at least three years past. 

The following table shows the results obtained : — 

Table XX 



Class I. 

Dirty Houses containing Consumptives 

who Used no Precautions. 


Class II. 
Clean Houses con- 
taining Consumptives 
not sufficiently 
Careful. 


Class III. 
Dirty Houses 

in which 
Consumptives 
had not Lived. 


The number of houses from which 

dust was examined was ... 23 
The number to be excluded because 
the inoculated animals died rapidly 
after inoculation was ... 2 
The number found infective by inocu- 
lation (one by microscopic examina- 
tion only) was . . . . 14 

Thus the percentage of infected houses 

was ...... 66*6 

The average size of the infected rooms 

was 475 c - ft- 

The average size of the non-infected 

rooms was .... 368 c. ft. 
The lighting and ventilation was — 

Good in 5 positive and 
7 negative cases 
Fair in 1 positive and 
1 negative case 
Bad in 8 positive and 
1 negative case 
j Samples were taken at different levels 

in .... 16 houses 
1 Of these samples the number found 

infective was . . . . 13 
Of the infective samples the number 

near the floor was ... 9 
4 to 6 feet above the floor was . . 13 


10 


5 

50*0 

336 c. ft. 

506 c. ft. 

In 1 positive and 
5 negative cases 

In 2 positive and 
negative case 

In 2 positive and 
negative case 


1 


D 

D 



The preceding results indicate that there is no necessary 



ioo THE PREVENTION OF TUBERCULOSIS 

relationship between cubic space and the number of tubercle 
bacilli in a room. The second series shows that ordinary 
cleanliness does not alone suffice to prevent the accumulation 
of infectious material in the rooms occupied by a consumptive. 
The third series shows, so far as a short series of experiments 
can, that tubercle bacilli are not present except in the immediate 
environment of consumptives. The results obtained in further 
experiments are interesting. 

Five specimens of dust were collected at various elevations 
from the walls of the waiting-room of the out-patients' depart- 
ment of the Hospital for Consumption in Manchester. This 
waiting-room is a lofty, well-lighted, and well-ventilated hall, 
used by 180 patients every morning. Ten guinea-pigs were 
inoculated and killed five weeks afterwards. None of them 
showed any signs of tuberculosis. 

Five samples of dust were also examined from the waiting- 
room of one of the large general hospitals, and here also the 
results were negative. 

Dust taken from railway carriages failed to produce tuber- 
culosis, but two samples taken from a general waiting-room 
at a railway-station both produced tuberculosis. 

Tubercle bacilli have been frequently found in the dust of 
railway carriages, omnibuses, and tram-cars. 



CHAPTER XIII 

CIRCUMSTANCES LIMITING THE AMOUNT OF INFECTION 
BY DUST AND SPRAY 

i. " IMITED Opportunities for Infection. — We have seen 
1 j that on the assumption that each annual death from 
phthisis implies the constant presence in the general 
population of three infective cases of the same disease, one in 
every 263 of the population of England and Wales is infective, the 
highest proportion being at ages 35 to 55 (p. 63). Even if we 
assume that ten instead of three infective phthisical patients 
are constantly present in the population for every death from 
phthisis, the proportion will only be 1 in 79 of the total popula- 
tion. Probably from the point of view of active infectivity three 
years is a much more likely duration than ten years. 

There is little if any foundation for the loose statements as to 
the ubiquity of the tubercle bacillus. It is true that one-twelfth 
of the total deaths from all causes are due to phthisis (p. 8), and 
that at certain ages as many as half the bodies of persons having 
died from other diseases have been found to present old healed 
or latent tuberculous lesions (p. 48). One cannot, however, argue 
from these data that at any given time a large proportion of the 
population are capable of infecting others with tuberculosis. 
The figures need to be considered, not in relation to deaths from 
other causes, but in relation to the total population ; and when 
this is done, the proportion of phthisical persons, on the three 
years' basis stated above, is only 1 in 1881 of the children aged 
5-10 years, 1 in 1129 of the children aged 10-15, and 1 in 141 of 
adults aged 25-35. 

2. Not every Consumptive is Infectious, and a Con- 
sumptive is not Infectious throughout the Whole of his 
Illness. — Careful patients do not endanger those with whom 
they live or work. The experiments recorded on pp. 98 and 100 
show that in rooms where consumptives use the simple pre- 



ioz THE PREVENTION OF TUBERCULOSIS 

cautions required, the dust is free from infective" material. (On 
this point see also pp. 91 and 92.) The experience of hospitals for 
consumptives appears to confirm the same conclusion. Those 
patients who habitually swallow their expectoration — and this 
includes nearly all children and lunatics — are relatively harmless 
except to themselves, assuming that the excreta are properly 
disposed of. 

Many consumptives again have no expectoration during a 
large part of their illness ; and in many others repeated examina- 
tion fails to detect tubercle bacilli. Thus of 326 undoubted 
cases of phthisis treated in the Brighton Borough Sanatorium 
during the three years 1903-05, 195, or 59*8 per cent., had tubercle 
bacilli in their expectoration during their stay in the sanatorium ; 
80, or 24*5 per cent., had throughout expectoration showing no 
tubercle bacilli ; and 51, or 157 per cent., had no expectoration 
at all. Most of these cases had either consolidation or cavitation 
of the lungs. Of course the failure to find tubercle bacilli in the 
expectoration of one-fourth of the total patients does not prove 
their entire absence in these cases ; and it is likely that in some 
of these cases inoculation experiments would have given positive 
results. It is almost certain, however, that a considerable pro- 
portion of the total cases, in addition to the sixth part who had 
no expectoration, were not a source of infection while under 
treatment, and probably not in a large part of the rest of their 
illness. It should be added that in nearly all the above cases 
three specimens of expectoration were examined before a negative 
return was made. On the other hand, Sir Hugh Beevor (1905), 
when examining the expectoration of 100 cases of phthisis 
(32 cavity cases and 68 without discoverable cavity), found that 
tubercle bacilli were absent in only about 15 per cent. 

The annual report of the Mount Vernon Hospital for Consump- 
tion for 1907 contains valuable data as to examination of sputum 
of patients, from which the table on the following page has been 
prepared. 

Thus of the total 678 patients 10 per cent, had no sputum 
while in the hospital, and of the 608 who had sputum 33 per cent, 
while in the hospital had no tubercle bacilli on repeated examina- 
tion. 

3. Consumptives differ greatly in Infectivity. — It has 
already been mentioned that when there is no expectoration 



LIMITING THE AMOUNT OF INFECTION 



103 



the danger of infection is absent, whilst when the expectoration 
is swallowed the danger is only to the patient himself. It may be 
taken as a rough guide, that (1) the danger varies with the amount 
of expectoration. This is not certainly true, and not always 
true. Abundant purulent expectoration may show no tubercle 
bacilli, and scanty expectoration may teem with them. The rule 
may, however, be taken as a useful practical guide, and it follows 
that advanced cases of phthisis in which expectoration is abundant 
present greater possibilities of infection than early cases (see also 
p. 394) . It appears probable that the danger from advanced cases 
may be greater than is implied by the above rule. Advanced 
patients are weak and may be bedridden, and under these circum- 
stances are less able carefully to control the hygienic disposal 





(See p 


Table XXI 

102 for Reference to this Table.) 




Condition of 
Patients. 


<*- 
its 



c 

fcJO 

"§ s 
B 


1 £ ' 

<** a, 

g c 


Is 

"SB 

5 


Number whose 

Sputum showed no 

Tubercle Bacilli 

on Repeated 

Examination. 


Percentage of 

Expectorating 

Patients in whom 

no Tubercle Bacilli 

were discovered. 


Infiltration of one 
lobe only . 

Infiltration of more 
than one lobe, 
but no cavitation 

Cavities present . 


198 

277 
203 


35 

25 
10 


18 

9 

5 


163 

252 
193 


93 

54 
11 


57 

22 
5 

1 



of their expectoration than if they were less enfeebled. The 
importance of careful and cleanly nursing at this stage needs to be 
emphasised. 

(2) The danger is great in proportion to the frequency of 
expectoration, infrequent expectoration being much more likely 
than frequent to be carefully deposited. 

(3) The number of tubercle bacilli in the expectoration is 
not a certain guide as to degree of infectivity. Dead tubercle 
bacilli take the stain for microscopic examination as well 
as living bacilli. Kitasato (quoted by Cornet, p. 83) proved 
experimentally that the majority of tubercle bacilli in expectora- 
tion or in cavities are already dead. When therefore Cornet 
gives a calculation showing that a single patient may expectorate 



104 THE PREVENTION OF TUBERCULOSIS 

daily 7200 million bacilli, and Nuttall that a patient with moder- 
ately advanced disease and expectorating from 70 to 130 c.c. daily 
may discharge daily from 1^- to 4J billions of bacilli, and when 
Bollinger estimated that 1 c.c. (about a quarter of a teaspoonful) 
may contain 810,000 to 960,000 bacilli, it must not be assumed 
that these are all living bacilli. Living bacilli will probably be 
present, quite sufficient to do mischief if the opportunity arises, 
but the possibilities of mischief are not so great as might at first 
be supposed. 

4. Virulent Bacilli have a Limited Extra-Corporeal 
Existence even when left alone. — In streets they cannot 
(p- 33 1 ) be found except in expectoration itself. In dwellings they 
have a more prolonged vitality, but according to Cornet infective 
material has usually disappeared from a dwelling after about six 
months. It is therefore, in all probability, an exaggeration to 
speak of a house as being saturated with the infection of years. 
One scarcely needs to add that it would be folly to trust to the 
slow processes of nature for removing infection, when by disinfec- 
tion and cleanliness this can be secured at once. 

5. Only a few Bacilli reach the Experimentally Deter- 
mined Duration of Extra-Corporeal Existence. — Direct 
sunlight kills them quickly (p. 53), being a disinfectant without 
peer. The dispersion produced by air currents minimises any 
subsequently received dose of infection, while street cleansing and 
the more effective scavenging produced by rain sweep infectious 
material into the sewers. It must be repeated that these factors 
are mentioned, not with the idea that we can afford to rest content 
with their operation without stopping indiscriminate expectora- 
tion, but to prevent exaggerated notions as to the possibilities 
of infection. 

6. The Dissemination of the Infectious Material dis- 
charged by Consumptives is Limited by its Physical Char- 
acter. — If the patient and his attendants and friends take the 
simple precautions required to prevent spray infection during the 
act of coughing, no immediate danger attaches to the expectora- 
tion. A lump of expectoration in its wet condition is absolutely 
incapable of spreading infection, except in the unlikely events 
of its smearing the hand, or being carried by flies or otherwise, 
and thus leading to the infection of food or of the cavity of the 
mouth directly. The tubercle bacilli are as safely imprisoned 



LIMITING THE AMOUNT OF INFECTION 105 

in the lump of expectoration as they would be in a bottle. 
Evaporation of the watery part of the expectoration is not 
accompanied by any escape of tubercle bacilli. Currents of air 
similarly have no effect. The bacilli cannot leave the expectora- 
tion so long as it is moist. Expectoration is not only moist 
but also viscid, and thus the tubercle bacilli often remain im- 
prisoned, even after all moisture has evaporated ; and sweeping 
or rubbing with boots, etc., is required to convert the expectora- 
tion into a condition of such dryness that its dissemination as 
dust becomes practicable. (On this point, see p. 92.) 

Even when expectoration becomes dust, and the particulate 
infective material can be scattered, it obeys the laws of gravity 
and tends to sink again after being disturbed. Hence a room 
which is very infective while sweeping is going on or soon after- 
wards may be occupied with relative safety an hour or two later. 
Tyndall's experiments demonstrating how particles of dust settle 
out of quiet air have clearly shown this. It must be repeated 
that it would be unreasonable to trust to the physical laws which 
minimise the risk of infection, and not to insist on the cessation 
of indiscriminate expectoration and on the wet cleansing of all 
occupied rooms and public places. 

7. The Air expired by Consumptives in ordinary Breath- 
ing is absolutely Sterile (see also p. 89). 

8. The circumstances which limit the amount of infection 
by presenting opposing forces to the invading bacilli will be 
considered later. (Chapters XXII. to XXVII.) 



CHAPTER XIV 

THE PORTALS OF INFECTION: A. INFECTION BY 
INHALATION 

APART from the ingestion of infected food, to be considered 
later, the predominant means of infection are the 
spray produced by the consumptive as he coughs or 
sneezes, and the dust of his powdered expectoration. Where 
do the tubercle bacilli thus received take root, and how do 
they reach those parts of the body in which the main lesions 
of tuberculosis are found ? 

They enter the body by the mouth or nostrils, and either 
(a) are passed through the mucous membrane of the mouth or 
naso-pharynx into the adjacent lymphatics ; or (b) are swallowed 
and lodge in the intestines and the mesenteric glands connected 
with them; or (c) are inhaled into the lungs. From any one 
of the points thus reached the tubercle bacilli may and commonly 
do pass on to other parts of the body. Lesions thus occur at 
definite points, but there is no need for the supposition that one 
part of the body is more susceptible than another to tuber- 
culosis. The lungs and the mesenteric glands, so far as we 
know, suffer more than other parts only because they are more 
exposed to invasion. 

That tubercle bacilli are inhaled by persons in contact with 
consumptives, or by animals subjected to experiments with 
tuberculous dust, has been repeatedly shown. Strauss found 
tubercle bacilli in the nasal cavities of various healthy persons 
frequenting the wards of the Charite and Laennec Hospitals 
in Paris ; of 29 persons employed in consumptive wards 9, of 
whom 6 were orderlies, gave positive results when tested by 
inoculation on guinea-pigs. St. Clair Thomson (1901) showed 
that in the healthy nose most of the bacteria inhaled are immedi- 
ately stopped at the nostrils (see also p. no). He quotes 
Liaras as having repeated Strauss's experiments under similar 



THE PORTALS OF INFECTION 107 

conditions on eighteen persons, but with precautions to secure 
cultures in each case from the interior of the nose and not from 
the nostril; the results were negative in each case. Notwith- 
standing the discrepant result of these observations, there is 
overwhelming evidence, both clinical and experimental, that 
tubercle bacilli may be inhaled and find their way by direct 
or indirect routes to the lungs. The subject may be conveniently 
discussed under the following heads : — 

1. By what means can the inhaled bacilli be checked ? 

2. At what points do the bacilli enter the tissues of the body ? 

3. What is the evidence that in phthisis the infection some- 
times reaches the lungs by inhalation, and not always indirectly 
by the lymphatic or blood circulations ? 

The general rule is that at whatever spot on or in the tissues 
of the body tubercle bacilli succeed in resisting phagocytic 
and other inimical agencies, there or in lymphatic glands con- 
nected therewith will tuberculosis develop. The usual course 
is for the tubercle bacilli to pass through the surface on which 
they have become deposited, and to be carried thence by the 
lymph stream. The lymphatic glands may act as filters pre- 
venting the tubercle bacilli from spreading to other parts of 
the body ; just as glands in the armpit may prevent general 
blood poisoning from a whitlow. Such carriage by the lymph 
stream is slow and largely barred by the glands. Rapid trans- 
port to more remote parts of the body can occur only when the 
bacilli have gained access to the blood vessels and are carried 
with the blood circulation. Then general or so-called miliary 
tuberculosis occurs, a relatively rare and late phenomenon in 
the disease. 

Means by which the inhaled Bacilli can be checked. — 
1. The Complexity and Shape of the Respiratory Passages. — Angles 
are met with in the nostrils, nasal cavity, pharynx, glottis, 
trachea, and bronchi, and at every successive angle the inhaled 
dust is filtered off. With quiet breathing, the greater part is 
stopped in the nostrils. 

2. The high Reflex Irritability of the Nasal and Pharyngeal 
Mucous Membrane. — The irritation produced by the presence 
of foreign particles may be so great as to cause sneezing and 
consequent expulsion of the offending particles, together with 
others too small to offend. 



108 THE PREVENTION OF TUBERCULOSIS 

3. The respiratory passages are lined with a coat of mucus ; 
and the individual cells are provided with cilia flicking all 
particles upwards towards the outlet. By this means a steady 
flow of mucus towards the pharynx is maintained, and a similar 
flow along the nose. Accumulated dust is thus swept into a 
position from which it can readily be ejected. Should the 
bacilli, notwithstanding the preceding impediments, succeed 
in obtaining lodgment in any part of the mucous membrane, 
they have then to do battle with the phagocytes of the body 
and the antibodies formed in connection with them. If 
victorious, the bacteria work their way into the underlying 
lymphoid tissue and along the lymph channels, and establish 
a primary focus of infection. 

Points of Entry. — If infective dust or droplets have 
passed the guarded portals of the mouth and nose, tubercle 
bacilli may penetrate the mucous membrane of the back of 
the nose, of the tonsils or larynx, of some lower part of the 
respiratory tract, or through decayed teeth. An obvious 
lesion may not develop at the point of penetration. This has 
been shown by Sidney Martin in the case of animals fed with 
tuberculous milk, a local ulcer being developed only when 
massive infection has been received; while only the subjacent 
lymphatic grands showed disease when the dose of infective 
material was more minute. 

Adenoid growths, so common in the post-nasal cavities of 
children before puberty, favour the occurrence of infection ; for 
they narrow the passage for air and hinder the expulsion of 
particulate matter. Naked -eye evidence of tuberculosis in 
adenoids is seldom seen ; but many observers have shown by 
microscopic examination or inoculation that tubercle bacilli are 
often contained in adenoids. Thus G. Morgan (1899) found 
tubercle bacilli in from 12 to 15 per cent, of his cases of adenoids 
in the substance of the morbid structure. Thomson (1901) 
gives a tabular statement of 1427 microscopic examinations 
of adenoids, in 5*1 per cent, of which tuberculosis was found. 
Dieulafoy similarly found tuberculous changes in 57 per cent, 
of his case of adenoids ; and the proportion was increased by 
inoculation experiments to 20 per cent. It seems likely, there- 
fore, that tubercle bacilli may enter at this point more often than 
is ordinarily supposed. 



THE PORTALS OF INFECTION 109 

The teeth possibly may also be the point of invasion. Thus 
G. W. Cook (quoted by Squire, 1906) found tubercle bacilli in 
the pulp of decayed teeth and in scrapings taken from and 
around the teeth, especially of the young. 

The tonsils probably play a considerable r6le as a primary 
site of tuberculous infection. The act of swallowing tuberculous 
dust or spray or food presses infective particles against the tonsils, 
in the crypts of which the infective matter may lodge. Like 
all lymphoid tissue, the tonsils are " on outpost duty, to arrest 
the invading bacilli/' and it is rather remarkable that active 
tuberculous disease of the tonsils is so seldom seen. Tubercle 
bacilli are often present in the tonsils without any naked-eye 
evidence of disease. On this point Latham (1900) has confirmed 
by the inoculation method the work of Woodhead and many 
others. He proved that the central portions of the tonsils of 
forty-five consecutive children aged from 3 months to 13 years 
showed evidence of tuberculosis in seven instances. Infection 
through the tonsils is common in pigs. It is probably more 
common in children than is usually supposed. 

The larynx is only exceptionally the seat of primary tuber- 
culosis, laryngeal implication being more often a symptom of 
advanced pulmonary tuberculosis. The trachea and bronchi 
are also seldom attacked, the inhibitory influences enumerated 
on page 107 rendering the infection of these parts infrequent. 

Infection of the Substance of the Lungs by Direct 
Inhalation is usually taught to be a frequent occurrence. We 
must now consider in detail the evidence for and against such 
direct inhalation. 

1. The Intricacies of the Respiratory Passages. — It is not sur- 
prising in view of these intricacies, and of the moisture and 
other influences tending to deposit dust during inspiration, that 
Cohnheim (1890) describes the air passages as forming a com- 
paratively long and narrow, closed and protected tube system ; 
while Virchow long upheld the view that dust could not find its 
way into the ultimate lung substance (quoted by Arlidge, 1892), 
arguing that the black pigment found in miners' lungs was due 
to altered blood pigment and not to carbon. In 1866, however, 
he was convinced that his former views on this point were 
incorrect. 

Against these mechanical difficulties must be set the facts 



no THE PREVENTION OF TUBERCULOSIS 

that during hard work breathing becomes more rapid and more 
laboured, and that the mouth is apt to be open; furthermore, 
that inspiration takes place over 20,000 times in the twenty-four 
hours, and often occurs in a very dusty atmosphere. Under 
these circumstances it need not be the subject of surprise that 
the defensive arrangements are occasionally overworked and fail 
to prevent invasion by infective dust. 

2. Experimental Evidence. — St. Clair Thomson and Hewlett 
(1895) having ascertained that at least 1500 organisms are inhaled 
into the nose every hour, and that in London it must be common 
for 14,000 to enter in an hour of quiet breathing, nevertheless 
found that the interior of the great majority of normal nasal 
cavities is perfectly aseptic (p. 106). They also confirmed Hilde- 
brandt's experiments made in 1888, in several instances the 
trachea of animals killed in the laboratory being found on opening 
to be free from bacteria. 

On the other hand, Zenker (quoted by Arlidge, p. 246) pro- 
duced red colouring of the substance of the lungs of animals by 
causing them to inhale a red dust ; and Knauff (quoted by 
Buck, p. 29), after inhaling particles of ultramarine for only ten 
minutes, found that the cells of his expectoration contained blue 
particles in their interior. In ultramarine workers the coloured 
dust has been recognised in expectoration fourteen days after 
cessation from work. Rabbits confined in a smoky atmosphere 
can be shown to have fine particles of carbon in their bronchi. 
Knauff (quoted by Greenhow, 1869) placed dogs for from one day 
to three months in a roomy chest, into which the fumes^of a smok- 
ing oil-lamp were conveyed by a flue opening through the floor. 
One dog killed after a single day in the smoke chest had the 
whole surface of the bronchial mucous membrane even to the 
alveoli of the lungs covered with a deposit of carbon mixed with 
mucus. Animals kept there for some weeks showed similar 
deposits throughout the lungs ; the lymphatic glands were very 
early affected. In animals confined for several weeks in the 
experimental chest there was almost invariably a deposit of 
carbon below the pleura. Control animals showed no similar 
appearances. 

It must be admitted, however, that none of these experiments 
is quite inconsistent with the view that the particles of pigment 
had been swallowed and reached the lungs by' means of the 



THE PORTALS OF INFECTION in 

lymph stream ; and the view that the pigment in miners' lungs 
and similar diseases owes an intestinal origin has in recent years 
been revived by the French school, especially by Villoret. Van 
Steenberghe and Grysez fed guinea-pigs and rabbits with food 
containing mixed coal dust and particles of Indian ink, finding 
at the autopsy on these animals pigment in the lungs only, the 
abdominal organs and mesenteric glands being free. Schultze 
(1906, Munch, med. Woch., liii. 1702) repeated these feeding 
experiments with similar results, but he is convinced that in 
feeding experiments, even when undertaken with the aid of a 
tube, inhalation cannot be excluded, and he explains in this 
way the deposit in the lungs. That this may be the correct 
explanation is supported by the fact that in a rabbit having 
a gastric fistula, through which he introduced pigments into the 
stomach daily for two months, no deposit was found post-mortem 
in the lungs. The experimental evidence, in short, cannot be 
said to have settled the question. 

3. Microscopic Evidence. — According to Rindfleisch (1875, 
p. 649), the first lesion in pulmonary tuberculosis occurs at the 
angles and projections situated where 

the smallest bronchioles become continu- 
ous with the acini. This can be readily 
understood from Fig. 12, if it be as- 
sumed that the tubercle bacilli have 
been inhaled into the acini. During 
coughing they will become lodged in the 
crannies around the opening of the bron- 
chiole (a), and disease consequently may 
start here. The diameter of a minute ^n^^itrgedLlJ^; 
branch of the bronchus at a is from 0*3 at a is the junction of the 

to 0*4 mm., as compared with "0015 to bronchiole with the acinus 

•004 mm., the size of a tubercle bacillus. 

4. Clinical experience supports the view that direct inhalation 
of infective particles into the lung substance is at least excep- 
tional. In 1868 Mr. (now Lord) Lister showed that suppuration 
did not follow when air had escaped into the pleura through 
injury of a lung by a fractured rib, thus indicating that the 
inspired air is probably sterile. His exact words are as follows: — 

Why air introduced into the pleura through a wounded lung should 
have such totally different effects from that entering through a per- 




ii2 THE PREVENTION OF TUBERCULOSIS 

manently open penetrating wound from without, was to me a complete 
mystery till I heard of the germ theory of putrefaction, when it at once 
occurred to me, though we could not suppose the gases of the atmosphere 
to be in any way altered in chemical composition by passing through 
the trachea and bronchial tubes on their way into the pleura, it was only 
natural that they should be filtered of germs by the air passages, one of 
whose offices is to arrest inhaled particles of dust, and prevent them from 
entering the air cells. 

5. The relative infrequency of tuberculosis of the larynx is 
adduced as evidence of the completeness with which filtration 
of the inspired air is effected in the naso-pharynx. St. Clair 
Thomson (1901) found in 100 autopsies in pulmonary tuber- 
culosis that only 30 had laryngeal disease ; and in another series 
that only 1 in 450 had tuberculous nasal disease. But, as already 
explained, the relative immunity of the larynx is probably due to 
the freedom of movement of its parts, the violent coughing ac- 
companying local irritation in it, and the active secretion of 
fluid washing away invading particles. Primary tuberculosis of 
the larynx occurs sometimes, but it is the exception. 

The evidence briefly summarised above is conflicting. In 
view of what we know to occur in knife-grinders and in lead and 
slate miners, as well as of the evidence given above, the balance 
leans to the conclusion that direct inhalation of dust into the 
lungs occurs. Such dust, if it carries with it the tubercle bacillus, 
may be regarded as an inoculating needle, securing a firm foot- 
hold for the bacillus in the pulmonary tissues. 

Infection of the Lungs otherwise than by Direct 
Inhalation. — Though it be agreed that the lungs may be in- 
vaded directly during inhalation, this is certainly not the only 
means of infection. The lungs may also be infected secondarily 
through the following channels : — 

(a) Through the bronchial glands. Tuberculous material is 
arrested at the tonsils or elsewhere, and the bacilli pass to the 
cervical and bronchial glands by the lymph stream. Sims 
Woodhead's experiments (1898) on a series of pigs fed with milk 
containing tubercle bacilli throw light on this question. The 
line of invasion could be traced in these pigs from the tonsils 
and lymphoid tissues of the throat to the neighbouring lymphatic 
glands along the neck ; thence to the upper part of the chest, 
to the glands at the root of the neck and the pleura. In this 
connection must be noted the frequency with which, in man, 



THE PORTALS OF INFECTION 113 

pleurisy precedes other signs of pulmonary tuberculosis. Wood- 
head's conclusion is as follows : — 

I am driven to the conclusion that this method of infection of the 
glands of the neck through the tonsils must be a comparatively frequent 
occurrence, especially in children under insanitary conditions, and sub- 
jected to various devitalising influences. 

There can be little doubt that the infection may spread 
downwards to the bronchial glands and then into the lungs, and 
that this is a fairly common method of infection, especially in 
children. That this is so is confirmed by the fact that in children 
the parts of the lungs near their roots are often most affected by 
tuberculosis. According to H. Walsham (1904), 

it is still an open question whether or not the lung can be infected by the 
gradual extension of the bacilli downwards with the lymph stream. I 
think in these cases where we find tuberculous change in the cervical 
glands further advanced than in the bronchial, we may assume that 
the lung has been infected in this manner. 

Case 4, p. 66, is probably one of phthisis originating in this 
way. It is not unlikely, however, that as in the case of intestinal 
infection (p. 116) the first chain of glands, in this case the cervical, 
may escape obvious involvement, the bronchial glands suffering 
most. 

The bronchial glands themselves may be infected from two 
sources : (a) from the cervical glands, and probably from the 
tonsils, as indicated above ; (b) from the alimentary canal. 
Thus Woodhead has traced tuberculosis from a caseous or old 
calcareous mesenteric gland through the chain of retro-peri- 
toneal glands up through the diaphragm to the posterior 
mediastinal and bronchial glands, and thence to the lungs. 

According to Guthrie, to the above methods of access to the 
mediastinal and bronchial glands must be added the possible 
passage of bacilli, swallowed with mucus or food, through the 
oesophageal lymphatic plexus to the posterior mediastinal 
glands. Squire (1906) believes that the implication of the 
bronchial glands is oftener produced in the reverse direction, 
from lungs to glands, than is usually accepted. 

(b) Through the alimentary canal. This will be considered 
separately in the next chapter. 

(c) Through the blood stream. The lungs may be infected 
8 



H4 THE PREVENTION OF TUBERCULOSIS 

by tubercle bacilli carried in the blood circulation. This circu- 
lation of infective products undoubtedly happens in general 
tuberculosis, as Buhl showed in* 1857 (p. 37). A caseous nodule 
breaks down, its contents enter the blood vessels, are carried to 
the heart and thence in the round of the circulation. It is likely 
that a more localised distribution of infection occurs by the blood 
vessels, when tuberculous material ulcerates into a blood vessel 
in the lung, and the disease spreads with the blood current to 
other parts of the lung. According to Volland (Cornet, p. 182), 
pulmonary tuberculosis is produced by bacilli which have entered 
the cervical glands and are carried thence within the leucocytes 
by way of the lymph stream and the lesser circulation to the 
lungs. We shall discuss later what means, if any, can be used 
to determine whether a given fatal case of tuberculosis has been 
caused by inhalation or ingestion ; and, if the latter, whether 
through the ingestion of human or of bovine infectious material. 



CHAPTER XV 

THE PORTALS OF INFECTION : B. INFECTION BY 
INGESTION 

THE arguments for and against the direct invasion of the 
lungs by inhaled particles have been given in the last 
chapter. If direct infection by way of the lungs is escaped, 
it does not follow that no infection occurs. As we have already 
seen, the individual may be infected through the mouth, naso- 
pharynx, or oesophagus. The next possibility of infection is 
through the stomach. Little is known of this, as separate from 
intestinal infection, and the subsequent course of the bacilli 
would be almost the same in both instances. In passing we may 
note 

The Effect of the Gastric Juice on swallowed Tubercle 
Bacilli. — Falk and Wesener exposed tuberculous material to 
the action of an artificial gastric juice for some hours, and showed 
that it had not lost its virulence when tested by inoculation on 
animals. Strauss and Wurtz subjected pure cultures of the 
avian tubercle bacillus to the action of a dog's gastric juice, and 
found that at the end of eight to twelve hours the bacilli were still 
able to produce local tuberculosis when inoculated on animals. 
It must be remembered, however, that the fat-splitting enzyme of 
gastric juice is very sensitive to its environment, and is destroyed 
quickly when the juice is used in vitro. Probably the fatty 
envelope of the tubercle bacillus would be more readily dissolved 
within the stomach than in an experiment under artificial con- 
ditions. Nevertheless in the stomach the digestive or inhibitory 
effect of the gastric juice would be diminished by dilution with 
food and fluid, and many tubercle bacilli would doubtless pass 
on unharmed into the small intestine. 

The Lesions produced by Ingested Tubercle Bacilli. — 
Most of these follow on the passage of the bacilli through the 

intestinal mucous membrane. The local effect on the mucous 

"5 



n6 THE PREVENTION OF TUBERCULOSIS 

membrane varies with the dose and the virulence of the bacilli, 
and possibly with the age of the patient. Sidney Martin's 
experiments in feeding pigs with tuberculous material showed 
that there need not be a local development of tuberculosis at the 
point of entry of the bacillus (see also p. 113), but that such 
lesions occurred when major doses of a more virulent strain were 
given. 

It might be argued that in these cases infection had not come 
vid the intestine. Thus Cadeac (quoted by Miiller, 1905) believes 
that in most feeding experiments, the tubercle bacilli enter in 
the region of the mouth and pharynx. Having fed guinea-pigs 
with material rich in bacilli, he killed them at the end of seven days, 
and tested the glands of the head and of the mesentery by inocula- 
tion, obtaining a negative result in the latter, a positive in the 
former case. Miiller has found that in guinea-pigs fed with 
infected milk the mesenteric glands may be primarily affected. 

A. Calmette and A. Guerin experimented on young goats 
suckled from their mothers' teats, which had previously been 
made tuberculous by the artificial introduction of tuberculous 
material into the mammary gland. They all acquired intestinal 
tuberculosis, followed by mesenteric disease. Then a number of 
adult goats were fed with tuberculous material by means of an 
oesophageal tube. These all contracted grave and rapidly fatal 
pulmonary tuberculosis, without obvious intestinal and with 
only a few mesenteric lesions. They concluded that in adults 
tubercle bacilli pass easily through the mesenteric lymphatic 
glands to the thoracic duct, and thence through the heart and 
pulmonary arteries of the lungs. 

The Second Interim Report of the Royal Commission on 
Tuberculosis (1907) gives the details of experiments in which 
calves were fed with the milk of cows whose udders had been 
made tuberculous by intra-mammary injection. It was found 
that in only one out of six calves thus fed was general tuberculosis 
produced, the tuberculosis in the others being confined chiefly 
to the intestines and mesenteric glands. Fourteen cows fed with 
tuberculous milk from various sources showed chiefly mesenteric 
lesions. On the other hand, generalised progressive tuberculosis 
was readily produced in monkeys by feeding them with tuber- 
culous milk. 

The experiments of Calmette and Guerin indicate that tuber- 



THE PORTALS OF INFECTION 117 

culosis of the bronchial glands and of the lungs may be the 
result of feeding with tuberculous material, with or without 
mesenteric disease ; but it appears likely that in human tuber- 
culosis due to ingestion, implication of the mesenteric glands is 
generally more abundant and more severe than that of other 
parts of the body. 

The age of tuberculous lesions is judged by the presence or 
absence of caseation or calcification ; these signs being taken to 
indicate an older lesion than tuberculous disease in which these 
degenerative changes have not occurred. On the value of such 
evidence in experimental animals, Professor Delepine (1898, 
p. 734) may be quoted : — 

There are very often clear indications in the body of the victim showing 
the channels through which the bacilli have penetrated. We have seen 
how the bacilli infect first the lymphatic glands nearest to their point 
of entrance. The lymph coming from the intestine passes first through 
the mesenteric glands. The lymph from the lungs passes in the same 
way through the bronchial glands. It is therefore evident that in the 
event of the bacilli penetrating through the intestine the mesenteric 
glands would be chiefly affected, and in the case of lung infection the 
bronchial glands would be most involved. There are cases in which 
death occurs before any other glands than those first invaded have had 
time to become diseased ; in such cases the state of the glands will clearly 
indicate the channel through which the bacilli have entered. 

In a series of over 300 experiments I have found that tuberculosis of 
the mesenteric glands occurs extremely late in guinea-pigs infected through 
other channels than the intestinal canal and the peritoneal cavity, and 
am absolutely convinced of the value of lymphatic glands as indicators of 
the path followed by tubercle bacilli in cases which have died before the 
disease has become too advanced. According to Dr. Woodhead, the 
post-mortem examinations of the bodies of tuberculous children who 
had died before the age of five and a half years show that in the large 
majority of them the intestine and mesenteric glands were affected, and 
that in 14 per cent, of those cases the mesenteric glands alone were 
tuberculous. 

Notwithstanding somewhat discrepant results from experi- 
ments, we may, I think, assume that the evidence of death- 
returns and still more of post-mortem examinations, gives some 
indication of the relative frequency of intestinal and of more 
direct pulmonary infection. 

Age Incidence of Death-rate from the different Forms 
of Tuberculosis. — The following table, which I have calculated 



n8 



THE PREVENTION OF TUBERCULOSIS 



from the Registrar-General's returns, shows the age incidence of 
the death-rate from the three chief forms of tuberculosis : — 

Table XXII. — England and Wales, 1901 
Death-rate per 100,000 Persons living at each Age-period 



°-5- 


5-io. 


10-15. 


15-20. 


20 and 
upwards. 


Pulmonary Tuberculosis . . 1 31 
Tuberculous Meningitis . . ! 109 
Tabes Mesenterica . . . 1 125 

I 


20 
27 
10 


41 
12 

7 


90 
6 

5 


176 
2 

3 



Even if a large deduction be made for errors of diagnosis and 
certification in the returns of tuberculous meningitis and tabes 
mesenterica, it still remains true that there is an inverse relation 
between the age incidence of death from those two diseases 
and that of death from phthisis. Whether, as adults take 
much less uncooked cows' milk than children, it may be inferred 
with safety that respiratory infection is more common in adult 
life and digestive infection in childhood, is still open to doubt. 
An a 'priori probability to this effect is created ; but this is some- 
what shaken by our knowledge of the different channels through 
which the lungs may become infected. It is quite possible 
that phthisis originating vid the digestive tract may be more 
frequent than the above table would indicate. 

Evidence from Autopsies. — The evidence from autopsies 
as to which are the oldest lesions is apt to be disturbed by the 
fact that, no examination being possible until natural death 
occurs, the bronchial and mesenteric glands may appear to be 
implicated equally. Possibly also the changes may occur more 
rapidly in certain lesions than in others. Thus in guinea-pigs 
lesions advance more rapidly in lymphatic glands than in lungs. 
Furthermore, as pointed out by H. W. Russell, lesions in lym- 
phatic glands are more easily detected than equally large lesions 
in a large organ like the lung. These sources of error possibly 
explain some of the discrepancies in the results of autopsies made 
at different hospitals, of which the following are examples : — 

Dr. L. G. Guthrie (1899) tabulated 77 post-mortem examina- 
tions made on tuberculous children at the Paddington Children's 
Hospital. He found tuberculosis of the various thoracic organs 



THE PORTALS OF INFECTION 119 

(lungs, pericardium, and pleura) in the aggregate of all the cases 
examined 105 times, of the various abdominal organs (peri- 
toneum, intestine, spleen, liver, kidneys, and pancreas) 102 
times, of the brain and meninges 41 times, and of the bones and 
joints 6 times. He notes the difficulty in determining the start- 
ing-point of infection from the stage of the lesions produced ; but, 
adopting the usual method of deciding the source of disease, he 
found that of the yy cases, thoracic tuberculosis was most pro- 
minent and apparently primary in 42 (54*5 per cent.), and 
abdominal tuberculosis in 19 (24*6 per cent.). In 7 of the re- 
mainder (16) the thoracic organs were as much affected as the 
abdominal. In 6 cases the origin was not discovered, and 3 
single cases originated elsewhere. The thoracic glands were 
found in a state of caseation 46 times, and the abdominal glands 
31 times. Both sets were caseous in 15 cases ; in 3 neither set 
was affected, and in 12 their condition was not noted. Thus 
the glands were caseous in 62 cases, or 80*5 per cent, of the total. 
Dr. Guthrie adds that he has not regarded mere caseation as 
evidence of primary glandular infection, and that he could only 
trace the origin of tuberculosis with any degree of certainty in 
41*5 per cent, of the cases — to the thoracic glands in 17 cases 
and to the mesenteric glands in 15. 

Dr. Guthrie summarises other experiences as follows : — 

MM. Rillet and Barthez found the origin in caseous bronchial glands 
in 79 per cent, and in mesenteric glands in 46 per cent, of cases. Sim- 
monds discovered caseous bronchial and tracheal glands in 73 per 
cent, and caseous mesenteric glands in 46 per cent., whilst Dr. Walter 
Colman attributed the origin to caseous thoracic glands in 79 per cent, 
and to mesenteric glands in 66 per cent, of his cases. 

He adds : — 

The discrepancy between these statistics and my own may be due 
to the fact that I have discarded the glands as the primary source of 
infection unless they have been both obviously caseous, and also associated 
with miliary, or at all events comparatively recent, tuberculosis else- 
where. 

Dr. Still (1899) concluded from post-mortem examinations of 
269 children under 12 years of age that the most common 
channel of infection in children is through the lungs ; that 
infection through the intestine is less common in infancy than 



120 THE PREVENTION OF TUBERCULOSIS 

in later childhood ; and that milk cannot be the usual source 
of infection. Dr. A. Latham, tabulating over 3000 post-mortem 
results on children, says they show that in children tuberculosis 
of the bronchial glands is the lesion most constantly found, and 
that disease is in the majority of instances most advanced in 
these glands. He deprecates the inference that infection has 
necessarily been conveyed aerially, and considers that infected 
milk supply plays an important r6le. 

Dr. Kingsford (1904) has added further cases and tabulated 
the results of previous observers in an excellent paper. 

It would be easy to give further figures, but they are all 
inconclusive. It cannot be regarded as settled, to what degree 
human tuberculosis is due to direct inhalation into the lungs, 
to entrance of infective material through the tonsils, etc., 
and to intestinal infection. Much less is this point settled for 
pulmonary tuberculosis. For a large proportion of intestinal 
may be and probably is secondary to pulmonary tuber- 
culosis ; and tuberculous meningitis may be secondary to an 
earlier focus of tuberculosis in any part of the body. Con- 
versely, a large, possibly the largest, part of pulmonary tuber- 
culosis may be due not to the direct inhalation of infective 
material into the lungs, but to secondary implication of the lungs 
from the neighbouring glands. And these glands or the pul- 
monary disease itself may furthermore have been the nidus of 
potential and eventually active pulmonary tuberculosis for many 
years before the latter disease comes into active existence. The 
evidence needs to be sifted with the utmost care in each indivi- 
dual case. Even then, the final decision arrived at after a 
careful balancing of all the available evidence cannot be regarded 
as certain. But the same remark applies to a large proportion 
of the broader problems of medicine ; and we are not relieved 
thereby from the responsibility of adjudicating and of taking 
practical measures based on our decisions. The obviously safe 
plan is to guard against all the possible sources of tuberculous 
infection that have been considered, though the greatest im- 
portance must be attached to the prevention of the inhalation or 
swallowing of dried expectoration or expectoration in the form 
of spray. 



CHAPTER XVI 
RELATION OF BOVINE TO HUMAN TUBERCULOSIS 1 

IN the earlier attempts to diminish tuberculosis, the pre- 
vention of infection by means of food bulked very largely. 
The only foods which are of importance in this connection 
are cows 5 milk and its products, and the flesh of the ox and 
pig. Inasmuch as cows' milk is the chief possible non-human 
source of tuberculosis in man, the question becomes in the main 
one as to the relation between bovine and human tuberculosis. 
The earlier view is summarised in the following remarks from 
the Report of the Royal Commission appointed to inquire into 
the Effect of Food derived from Tuberculous Animals (1895) : — 

Par. 22. As regards man, we must believe — and here we find our- 
selves agreeing with the majority of those who gave evidence before us — 
that any person who takes tuberculous matter into the body as food, 
incurs some risk of acquiring tuberculous disease. . . . 

Par. 23. We regard the disease as being the same disease in man and 
in the food animals, no matter though there are differences in the one 
and in the other in their manifestations of the disease ; and we consider 
the bacilli of tubercle to form an integral part of the disease in each, and 
(whatever may be its origin) to be transmissible from man to animals 
and from animals to animals. 

In Par. 80 of the report of the same Royal Commission it 
is stated emphatically that " no doubt the largest part of the 
tuberculosis which man obtains through his food is by means 
of milk containing tuberculous matter." 

The views stated above were generally entertained by 
Koch among others, judging by his statement in 1882 (Berliner 
klin. Wochenschr., 1882, p. 230) that " bovine tuberculosis is 

1 This and the next two chapters were written before the appearance of 
the second Interim Report of the Royal Commission appointed to inquire into 
the Relations of Human and Bovine Tuberculosis. Any modifications necessi- 
tated by that important report are added in footnotes, or in special paragraphs. 



122 THE PREVENTION OF TUBERCULOSIS 

identical with human tuberculosis, and is thus a disease trans- 
missible to man." 

In 1901, Koch gave his famous address at the meeting of 
the British Congress on Tuberculosis. In this address he said : — 

This manner of infection is generally regarded nowadays as proved, 
and as so frequent that it is even looked upon by not a few as the most 
important, and the most rigorous measures are demanded against it. 
In this Congress also the discussion of the danger with which the tubercu- 
losis of animals threatens man will play an important part. 

After excluding the tuberculosis of poultry, which differs 
so much from human tuberculosis that it can be left out of 
account as a source of infection for man, he added, 

the only land of animal tuberculosis remaining to be considered is the 
tuberculosis of cattle, which, if really transferable to man, would indeed 
have frequent opportunities of infecting human beings through the 
drinking of the milk and the eating of the flesh of diseased animals. 

After indicating the obvious impossibility of investigating 
the problem by direct experiments on human beings, Koch 
said : — 

Indirectly, however, we can try to approach it. It is well known that 
the milk and butter consumed in great cities very often contain large 
quantities of the bacilli of bovine tuberculosis in a living condition, as 
the numerous infection experiments with such dairy products on animals 
have proved. Most of the inhabitants of such cities daily consume such 
living and perfectly virulent bacilli of bovine tuberculosis, and unin- 
tentionally carry out the experiment which we are not at liberty to make. 
If the bacilli of bovine tuberculosis were able to infect human beings, 
many cases of tuberculosis caused by the consumption of alimenta con- 
taining tubercle bacilli could not but occur among the inhabitants of 
great cities, especially the children. 

His remarks on this point will need discussion later (p. 131), 
but in the meantime we may quote his conclusion, which is that, 

though the important question whether man is susceptible to bovine 
tuberculosis at all is not yet absolutely decided, and will not admit of 
absolute decision to-day or to-morrow, one is nevertheless already at 
liberty to say that, if such a susceptibility really exists, the infection of 
human beings is but a very rare occurrence. I should estimate the extent 
of infection by the milk and flesh of tuberculous cattle and the butter 
made of this milk, as hardly greater than that of hereditary transmission, 
and I therefore do not deem it advisable to take any measures against it. 

This important expression of opinion involved a re-testing 
of the whole question of the relationship between bovine and 



BOVINE AND HUMAN TUBERCULOSIS 123 

human tuberculosis, and since Koch's address many have 
been working at the problem. In England a Royal Commission 
was appointed to inquire into the Relations of Human and 
Animal Tuberculosis, and in 1904 it issued an interim report, 
from which the following extract is taken : — 

We have up to the present made use, in the above inquiry, ol more 
than twenty different " strains " of tuberculous material of human 
origin, that is to say, of material taken from more than twenty cases of 
tuberculous disease in human beings, including sputum from phthisical 
patients and the diseased parts of the lungs in pulmonary tuberculosis, 
mesenteric glands in primary abdominal tuberculosis, tuberculous 
bronchial and cervical glands, and tuberculous joints. We have com- 
pared the effects produced by these with the effects produced by several 
different strains of tuberculous material of bovine origin. 

In the case of seven of the above strains of human origin, the intro- 
duction of the human tuberculous material into cattle gave rise at once 
to acute tuberculosis, with the development of widespread disease in 
various organs of the body, such as the lungs, spleen, liver, lymphatic 
glands, etc. In some instances the disease was of remarkable severity. 

In the case of the remaining strains, the bovine animal into which 
the tuberculous material was first introduced was affected to a less extent. 
The tuberculous disease was either limited to the spot where the material 
was introduced (this occurred, however, in two instances only, and these 
at the very beginning of our inquiry), or spread to a variable extent from 
the seat of inoculation along the lymphatic glands, with, at most, the 
appearance of a very small amount of tubercle in such organs as the 
lungs and spleen. Yet tuberculous material taken from the bovine 
animal thus affected, and introduced successively into other bovine 
animals, or into guinea-pigs from which bovine animals were subsequently 
inoculated, has, up to the present, in the case of five of these remaining 
strains, ultimately given rise in the bovine animal to general tuberculosis 
of an intense character ; and we are still carrying out observations in this 
direction. 

We have very carefully compared the disease thus set up in the bovine 
animal by material of human origin with that set up in the bovine animal 
by material of bovine origin, and so far we have found the one, both in 
its broad general features and in its finer histological details, to be identical 
with the other. We have so far failed to discover any character by which 
we could distinguish the one from the other j and our records contain 
accounts of the post-mortem examinations of bovine animals infected 
with tuberculous material of human origin, which might be used as 
typical descriptions of ordinary bovine tuberculosis. 

The result at which we have arrived, namely, that tubercle of human 
origin can give rise in the bovine animal to tuberculosis identical with 
ordinary bovine tuberculosis, seems to us to show quite clearly that it 
would be most unwise to frame or modify legislative measures in accord- 
ance with the view that human and bovine tubercle bacilli are specifically 



124 THE PREVENTION OF TUBERCULOSIS 

different from each other, and that the disease caused by the one is a 
wholly different thing from the disease caused by the other. 

The preceding sketch of a few of the most prominent features 
in the history of this moot point would not be complete without 
noting that in 1896 Professor Theobald Smith first drew atten- 
tion to certain differences between bacilli from human and 
bovine sources, and in 1898 he classed human and bovine bacilli 
as separate types or races. Although the evidence which he 
advanced had been somewhat neglected until Koch published 
the results of his limited series of experiments, the idea that there 
are two types of tubercle bacillus bearing on human disease, 
the Typus humanus and the Typus bovinus, is by no means new. 

Differences between Human and Bovine Tuberculosis. 
— 1. Differences in Morphological Characters of the Bacilli. — The 
bovine bacillus is more uniform and constant in form than the 
human bacillus. It is thick, straight, and short, seldom more 
than 2 (jb in length, and averaging less (Theobald Smith). 
Human bacilli are larger from the start and tend to increase in 
length at once in subculture. They are generally more or less 
curved. These morphological differences tend to disappear in 
the tissues of susceptible animals. The bovine bacilli stain 
deeply with carbol-fuchsin, beading being nearly always absent 
from young cultures and often from old ; human bacilli stain 
less intensely with carbol-fuchsin, and beading is generally 
seen, even in early growths. 

2. Differences in Growth in Media. — Bovine bacilli, according 
to the same authority, grow more luxuriantly in artificial media 
than human bacilli, especially in glycerinised broth. 

3. Differences in Reaction. — Theobald Smith has 

called attention to the difference in the movement of the reaction of 
the glycerin bouillon in which bovine and human bacilli are multiplying. 
In the case of the bovine cultures this movement leads to a final reaction, 
either neutral, feebly alkaline, or feebly acid, toward phenolphthalein ; 
in case of the human cultures to a pronounced acidity to phenolphthalein. 
In the latter the reaction at first becomes less acid, then either much 
more acid, or else it remains at a medium level. 1 

1 According, however, to the experimental work done by Dr. A. S. Griffith for 
the Royal Commission on Tuberculosis (vol. iii. of Appendix to Second Interim 
Report) these differences appear to be " differences in degree and not in kind, 
and are attributable to variations in saprophytic power which have been shown 
to exist on other media." 



BOVINE AND HUMAN TUBERCULOSIS 125 

4. Differences in Pathogenic Effect. — The bovine bacillus has 
a much greater pathogenic power than the human bacillus 
for all animals with which it has been inoculated ; except that 
in the pig and guinea-pig the susceptibility to both types of 
bacilli is so great that it is hard to distinguish between them 
(Ravenel, 1902, p. 26). Koch and Schiitz in their experiments 
found that in pigs also the bovine was much more active than 
the human bacillus. Rabbits have been found to withstand 
the injection of doses of human bacilli, when an equal dose of 
bovine bacilli caused fatal tuberculosis. The difference in 
pathogenic effect between the human and bovine type is even 
more obvious in the case of cattle. Thus a subcutaneous 
injection of 5 eg. of bacilli of the human type caused in cattle 
only a local reaction at the seat of infection and in the neigh- 
bouring glands, the local disease decreasing and not spreading 
to internal organs, " even after protracted observation," whereas 
the same dose of bovine bacilli caused disseminated tuberculosis 
(Kossel, 1905). The difference in the two types is especially 
marked when animals are fed with pure cultures of the bacilli. 
When animals have been dosed for three months with cultures 
of the human type, bacilli are found to have accumulated in 
the mesenteric glands, without any change there other than 
calcification, and always without that wider dissemination seen 
in experiments with the bovine type. 

Kossel draws attention to the necessity, in making compara- 
tive tests, of taking certain precautions, the ignoring of which 
may have caused some of the discrepant results published by 
different experimenters — (1) Comparable material alone should 
be used, — only young cultures, in which the same nutrient 
material has been employed. (2) Fresh strains of bacilli must 
be used, isolated recently from the animal body. (3) Faulty 
results have ensued from inoculating with pieces of tuberculous 
organs instead of with cultures. (4) Experiments should be 
on as wide a basis as possible. Kossel inoculated 27 different 
strains of bacilli of the bovine type and produced disseminated 
tuberculosis in 32 out of 33 cattle ; while the inoculation of 
38 different strains of bacilli of the human type into 44 cattle 
produced local lesions only. 

The above results can now be checked by the elaborate 
and protracted experimental observations of the English Royal 



126 THE PREVENTION OF TUBERCULOSIS 

Commission given in their Second Interim Report (1907). The 
experimental results of the work are summarised as follows by 
Sidney Martin : — 

GENERAL SUMMARY OF RESULTS OF THE ROYAL COMMISSION 

1. Bovine Tuberculosis 

(Thirty strains examined) 

The bacillus of bovine tuberculosis has been shown by the experiments 
to have certain characteristics as follows : — 

a. It shows some variations in its growth on artificial media, and 
according to these variations can be arranged into three groups or 
grades (I., II., III.). 

/3. When inoculated into bovines, rabbits, guinea-pigs, pigs, goats, 
monkeys, and the chimpanzee in appropriate doses it produces death 
by generalised tuberculosis. 

y. It shows stability as regards its cultural characters, both when sub- 
cultured and when passed through animals. Whether these characters 
can be altered by prolonged passage in certain animals is still the 
subject of experiment and cannot now be answered. 

8. It shows great stability in virulence both after long subcultivation 
and after passing through animals. 

2. Human Tuberculosis 

(Sixty cases examined) 

The bacilli of human tuberculosis show a greater variety than those of 
bovine tuberculosis. 

Group I 

(Fourteen cases examined) 

a. The bacilli obtained from the virus of human beings in this group 
have all the characters of the bacillus of bovine tuberculosis as regards 
cultural characters, virulence for the animals previously mentioned, and 
stability of cultural characters and of virulence. 

The bacillus of this group is identical with the bacillus of bovine tuber- 
culosis. 

/3. The bacillus of these cases was a single bacillus — there was no 
evidence of a " mixture " of different kinds of bacilli. 

y. The bacillus was the cause of death of the individuals from which it 
was obtained. This is more particularly shown by the study of Viruses 
H. 32 " Y.W.," H. 59 " L.B.," and H. 64 "M.G.," in which general tubercu- 
losis was the cause of death of the child. The disease started as abdominal 
tuberculosis, but became generalised. Culture not only from the mesenteric 
glands, but also from the bronchial glands and lungs and meninges, had 
the characteristics of the bovine bacillus in cultivation and in virulence. 
No mixture of bacilli was here present. The children died of an infection 
by the bacillus of bovine tuberculosis. 

This group includes three cases of cervical gland tuberculosis and eleven 
cases of abdominal tuberculosis. 



BOVINE AND HUMAN TUBERCULOSIS 



127 



Group II 

(Forty cases examined) 

The bacilli obtained from the virus of human tuberculosis in this group 
differs from the bacillus of bovine tuberculosis in the following points : — 

a. In culture they are more luxuriant and are distinguished as refer- 
able to Groups IV. and V. 

j3. When inoculated into calves and rabbits they do not produce the 
generalised and fatal disease caused by the bovine bacillus. 

The result of inoculation is not a negative one, but varies within 
certain limits with different viruses, and in rabbits the viruses oc- 
casionally kill the animal by producing a generalised disease. 

They agree with the characteristics of the bovine bacillus in the follow- 
ing points : — 

a. They produce general tuberculosis in monkeys and the chimpanzee. 

(3. The lesions produced in these animals are the same anatomically 
as those produced by the bovine bacillus. 

y. The lesions produced in calves and rabbits are histologically tuber- 
culosis, although usually they show retrogression. 

This group includes : — 

Sputum Culture . . . . .2 cases 

Pulmonary Tuberculosis 

General ,, 

Bronchial Gland „ 

Cervical Gland „ 

Abdominal ,, 

Joint 

Testicle „ 

Kidney ,, 

The experiments show, however, that this division into two groups of 
the bacilli found in human tuberculosis is not the whole question. 



10 


>» 


I 


case 


2 


cases 


6 


>> 


8 


„ 


9 


„ 


1 


case 



Group III 
(Six cases examined) 

The investigation of two viruses, H. 53 " D.H." and H. 49 " T.C." 
shows that bacilli are obtainable from cases of human tuberculosis 
which belong to neither group. The bacilli from the two viruses mentioned 
showed an irregular virulence in calves and rabbits, and one of them, 
H. 49 " T.C./' showed also (1) that the culture of the original material 
lost its virulence after prolonged subcultivation, and (2) that the original 
virus, although irregularly virulent for calves, became highly and uniformly 
virulent after being passed through a calf. The culture of H. 49 " T.C." 
obtained from the original material has in cultivation the characters of 
the bacillus of bovine tuberculosis, belonging to Grade II. There was no 
evidence of mixture in the case of either virus. 

The results of the examination of the bacilli in the case of these two 
viruses point to the conclusion that the bacilli were bovine in origin 
and had been altered by residence in the human being. 



128 THE PREVENTION OF TUBERCULOSIS 

As bearing intimately on this matter, the question of the transforma- 
tion of the human bacillus into the bovine as shown in the experiments 
previously discussed must be mentioned. 

When by passage through calves, the slightly virulent bacillus of 
human tuberculosis becomes apparently modified into the bovine bacillus, 
it was suggested that it was not a real modification, but that the original 
virus was a mixture of bacilli, and that during the passage the bovine 
bacillus alone survived. But in these passage experiments there is evi- 
dence that at the time when the virus is becoming virulent, the bacilli 
separated by culture are " unstable " in virulence for calves and rabbits ; 
an instability similar to that of the original virus of H. 49 " T.C." 

The consideration of these cases tends to bridge the gap between the 
bacilli of Group I. (bovine bacilli) and those of Group II., which they 
suggest may only be a form of bovine bacillus, degraded as regards viru- 
lence for calves and rabbits, by long residence in the human body. 

If bacilli of the bovine and human types have distinctive 
characteristics, and differ greatly in their pathogenic effects on 
cattle, the answer to the question, is tuberculosis in cattle pro- 
duced by the bacillus of the human type, must with certain 
limited exceptions be in the negative. It does not, of course, 
follow from this that human tuberculosis may not be caused 
by bacilli of the bovine as well as of the human type. The 
results obtained by the Royal Commission as well as by German 
and American observers indicate that bovine is at least an 
occasional cause of human tuberculosis. There may be said 
to be three schools of opinion on the subject : — 

1. Human and bovine tuberculosis are totally distinct diseases, 
and are not to any serious extent intercommunicable. This 
appears to be Koch's position, for in his Nobel Lecture (1906) 
he says : — 

We must attain to absolute clearness as to the manner in which in- 
fection in tuberculosis takes place — i.e. as to how the tubercle bacilli 
get into the human organism, for the sole purpose of all prophylactic 
measures against a pestilence must be to prevent the entrance of the 
germs of disease into man. Now, as regards infection with tuberculosis 
only two possibilities have hitherto presented themselves — namely, 
infection by tubercle bacilli emanating from tuberculous human beings 
and infection by tubercle bacilli contained in the flesh and milk of tuber- 
culous cattle. After the investigations which I have made hand-in-hand 
with Schutz as to the relation between human and bovine tuberculosis, 
we may dismiss this second possibility, or at least regard it as so slight 
that this source of infection as compared with the other falls quite into the 
background. We arrived, namely, at the result that human tuberculosis 
and bovine tuberculosis are different from one another, and that bovine 



BOVINE AND HUMAN TUBERCULOSIS 129 

tuberculosis is not transmissible to man. With reference to this latter 
point, however, I wish, in order to prevent misunderstandings, to add 
that in saying this I mean only those forms of tuberculosis that have 
to be taken into account in connection with the combating of tuberculosis 
as an epidemic disease — namely, generalised tuberculosis and above all 
pulmonary phthisis. ... I wish only to add that the testing of our in- 
vestigations which has been carried out with the utmost care and on a 
broad basis in the Imperial Office of Health in Berlin has led to a confir- 
mation of my opinion, and that, moreover, the harmlessness of the bacilli 
of bovine tuberculosis to man has been directly proved by the repeated 
inoculating of human beings with the material of bovine tuberculosis 
by Spengler and Klemperer. In connection with the combating of tuber- 
culosis, then, only the tubercle bacilli emanating from human beings 
have to be taken into account. 

2. The ingestion of bacilli of the bovine type is the essential 
cause of tuberculosis in the human being. The chief exponent of 
this view is von Behring, who, in his Cassel Lecture (1903), says : — 

Koch's assertion that there are essential differences between human 
and bovine tubercle bacilli, and that these differences are not bridged over 
by any connecting links . . . has since called forth observations from 
all over the world which positively demonstrate the existence of inter- 
mediary stages in the virulence of tubercle bacilli derived from mammals. 
Generally, tubercle bacilli derived from cattle are more virulent for all 
animal species thus far examined than are human tubercle bacilli. And 
the opinion is constantly gaining ground that bovine tubercle bacilli are 
also more virulent for man. 

His own special views are embodied in the following extracts 
from the same lecture : — 

According to my ideas there has not yet been a single well-authenticated 
case in which pulmonary consumption has originated in adults as the result 
of a tuberculous infection developing epidemiologically, i.e. under con- 
ditions essential for infection occurring in nature. 

His view is that in all cases in which phthisis is caused, 
apparently by human infection during adult life, there has 
been pre-existing tuberculosis of bovine origin, and he holds 
that 

considering the figures . . . showing the enormous diffusion of tuber- 
culosis, the objection is surely justified that the persons thus dying of 
consumption already had a tuberculous focus in the lungs, and that this 
pulmonary disease, under a mode of life favourable to tuberculosis, was 
converted into florid phthisis. 

9 



130 THE PREVENTION OF TUBERCULOSIS 

It is necessary to give further extracts from this lecture, 
in order to make von Behring's position quite clear. He concedes 

not only the possibility, but the actual occurrence of pulmonary tuber- 
culosis going on to consumption, as a result of infection of an adult person 
... in the sense that on the basis of an infantile infection a pulmonary 
tuberculosis has developed, which becomes manifest only through the 
agency of the additional infection. 

His chief contention is contained in the following words : — 

/ I believe I have discovered a new principle which may be expressed 
thus : 

The milk fed to infants is the chief cause of consumption. 

3. Human tuberculosis may be and is caused by bacilli of 
either the bovine or human type. This is the view most generally 
and justifiably entertained, supported as it is by the balance 
of all available evidence. The extracts from the Interim 
Report of the Royal Commission given on p. 126 show that bacilli 
of the human type are sometimes very virulent to cattle ; and 
the practical conclusion given in an earlier report (p. 123) of 
the same Commission as to the undesirability in the interest 
of man of relaxing precautions against bovine tuberculosis, 
must commend itself as reasonable. Thus Ravenel (1905, p. 147) 
says : — 

Theoretically, there is no reason why the bovine bacillus should not 
be readily transmitted to man. It has for all other mammalia on which 
it has been tried a virulence greatly exceeding that of the human tubercle 
bacillus. It would certainly seem a remarkable anomaly for man, 
who is one of the most susceptible of all animals to tuberculosis, to be 
immune to the most powerful virus known. In the whole range of com- 
municable diseases we have nothing comparable to this state of affairs, 
should we admit it. 

These three views will be next considered. 



CHAPTER XVII 

EVIDENCE OF THE OCCURRENCE OF BOVINE 
TUBERCULOSIS IN MAN 

THE occurrence of tuberculosis of bovine origin in man to 
an extent of practical importance is, as we have seen, 
denied by Koch and those who agree with him. What 
evidence is there for and against this view ? Tuberculosis might 
conceivably be produced in man by bacilli of the bovine type, (i) 
if these bacilli were themselves able to cause active disease in 
him ; or (2) if they were to survive in his tissues in a latent con- 
dition for a period sufficient to enable them to become changed 
into bacilli of the human type. 

What Evidence is there that Bacilli of the Bovine 
Type can cause active Tuberculosis in Man directly, 
without Conversion into the Human Type ? — The only 
satisfactory evidence available consists in finding, in the lesions of 
human disease, bacilli which conform to all the known distinctive 
tests of the bovine type, including those already given on p. 124. 
This evidence has been supplied by various workers. Thus Theo- 
bald Smith in 1898 made from the mesenteric glands of children 
two cultures, of which one was of human while the other 
was pronounced to be of bovine origin. At the same time he 
supplemented the studies made by Ravenel " upon a presumably 
bovine culture from a child, by applying a new reaction test " 
(described on p. 124). " This latter culture had also the char- 
acteristics belonging to the bovine bacillus." Later (1904, 
p. 9), he showed that the bacilli present in three cases of general 
tuberculosis — a child aged eight months and two adults — did not 
belong to the bovine type. In a paper published in 1905, Theobald 
Smith, after giving further cases fully worked out, states that 
Vagades (Zeitschrffiir Hygiene, 1898, xxviii. p. 276) found " one 
culture among 28 isolated from man, which, it seems to me, was a 

bovine bacillus/' He also quotes Lartigau {Journal of Medical 

131 



i 3 2 THE PREVENTION OF TUBERCULOSIS 

Research, 1901, vi. p. 156) as finding at least one bovine culture 
of maximum virulence among nineteen cultures of human source ; 
and he quotes Ravenel as having, like himself, isolated from 
mesenteric glands two cultures, of which one was of the human 
and the other of the bovine type. He emphasises (1905, p. 296) 
the fact that 

but few experimenters have taken the time necessary to isolate and 
carefully compare cultures. The literature does not therefore offer 
that precise basal information upon which far-reaching conclusions may 
be built. 

Since the above quotation was written, the Imperial Board of 
Health in Berlin and the English Royal Commission have both 
issued reports, the latter of which is quoted on p. 126. In the 
former Kossel (1905, p> 1448) states : 

The result of the far-reaching experiments conducted under my direc- 
tion in the Gesundheitsamt at Berlin has been to show that in human 
tuberculosis tubercle bacilli may exist that correspond in every respect 
in their morphological, biological, and pathogenic qualities to bacilli of 
cattle tuberculosis — that is, such as belong to the Typus bovinus. 

Among 56 cases of human tuberculosis we found these germs 6 times — 
that is, in 10 per cent, of the cases. It would, however, be erroneous 
to conclude from these figures alone that 10 per cent, of all cases of human 
tuberculosis in Berlin were caused by infection with tubercle bacilli of 
the Typus bovinus, and that for the following reason : We included 
in the number of our experiments chiefly cases in which we could assume 
that the tuberculosis owed its origin to an intestinal infection, and possibly, 
therefore, to food containing tubercle bacilli. 

Tubercle bacilli of the Typus bovinus appear chiefly in tuberculous 
lesions in children, and among our cases we found that, with one excep- 
tion, it was the mesenteric glands or intestinal ulcers that contained 
the bovine germs. When, on the other hand, the sputum of adults 
suffering from pulmonary phthisis was examined, only bacilli of the 
Typus humanus were found. That tubercle bacilli of the Typus bovinus 
can, however, also enter the adult body was ascertained by our finding 
them, together with those of the Typus humanus, in a case of extensive 
tuberculous ulcers of the intestines in a woman. 

Results of the English Royal Commission. — As already 
indicated, the bacilli obtained from sixty cases of human tuber- 
culosis were exhaustively examined by every known method, 
with the results as to type of bacillus set out on p. 126. These 
results are so important from other points of view that I have 
set them out in tabular form below, in a table modified from the 
table on p. 72 of the report of the above Commission, 



EVIDENCE OF BOVINE TUBERCULOSIS 



133 



Table XXIII 

Summary of Results of Examination of Different Strains of Human 
Tubercle Bacilli 



Nature of Case. 



1. Sputum (4 cases) . 

2. Primary Pulmonary Tu- 

berculosis (10 cases) . 



3. General Tuberculosis 

(1 case) 

4. Bronchial Gland Tuber- 

culosis (4 cases) . 

5. Cervical Gland Tuber- 

culosis (9 cases) . 

6. Primary Abdominal Tu- 

berculosis (19 cases) . 



7. Joint Tuberculosis (10 
cases) 



8. Tuberculosis of Testis (1 

case) .... 
Tuberculosis of Kidney 
(1 case) 

9. Lupus (1 case) 



Total 



Part used for 
Experiment. 



Sputum . 

Lung . . . 
Lung and cervical 
gland . 

Bronchial glands 

Bronchial glands 

Cervical glands 

Mesenteric glands . 
Mesenteric gland, 

cervical gland, 

meninges 
Mesenteric gland, 

bronchial gland . 
Mesenteric gland, 

lung, cervical 

gland, meninges . 
Mesenteric gland, 

meninges 
Mesenteric gland, 

lung, meninges 

Scrapings from joints 
Pus from lumbar ab- 



Testis 

Kidney . 

Scrapings of the 
lesions . 



It 



14 



C £S 

St s 



gpq 

>3 



'£& 



£33 fcjo c/j 



J-, w a « 

•kT «j o £ 

;> c o >- 



40 



134 THE PREVENTION OF TUBERCULOSIS 

It will be noted that 14 out of the total number of strains 
obtained from human sources conformed to the bovine type. 
Out of 19 cases of primary abdominal disease, in which infection 
might be through ingestion, 10 were of bovine type; out of 
8 cases of tuberculous cervical glands, in which similar infec- 
tion during swallowing might occur, 3 were of bovine type ; 
whereas only 1 strain of the bovine type was obtained from 
sputum out of 4 examined, and none from diseased lungs out 
of 10 examined. Of 4 cases of bronchial gland disease 2 were 
of the human type and 2 doubtful. Of 10 cases of joint 
tuberculosis, all were of the human type. 

It would be unjustifiable to infer from the above figures that 
probably 14 out of 60, or about 23 per cent., of all cases of human 
tuberculosis are derived from tuberculous cattle. If the single 
sputum case be omitted, the parts affected in the above cases of 
tuberculosis of bovine type are the mesenteric and cervical 
glands. But primary tuberculosis of these parts causes less than 
10 per cent, of the total mortality officially recorded as due to all 
forms of tuberculosis in this country. If the 28 cases of cervical 
and primary abdominal tuberculosis are assumed to be typical 
of what similar examination on a larger scale would show, it is 
noteworthy that 13 of these, i.e. about half, were of the bovine 
type. This would reduce the 10 per cent, above mentioned to 
5 per cent. ; and until further evidence accumulates it may be 
convenient to assume that from 5 to 10 per cent, of the total 
human mortality from tuberculosis is due to infection from 
bovine sources. 

This assumption will be subject to modification if future 
investigations show that the bovine bacillus can be transformed 
into the bacillus of the human type. We may next consider with 
advantage the evidence at present available on this point. 

What Evidence is there that Tubercle Bacilli of one 
Type can be transformed into Tubercle Bacilli of another 
Type ? — Many investigators hold that the characteristics given 
on p. 124 as distinguishing races of mammalian tubercle bacilli are 
variable elements, and can be modified by growing the bacilli in 
different culture media. Theobald Smith (1905, p. 297), however, 
observes : — 

This view, I think, would be rejected by all who have studied con- 
tinuously bacilli from different species. Virulence necessarily declines 



EVIDENCE OF BOVINE TUBERCULOSIS 135 

with prolonged cultivation, and bacilli may assume slightly different 
forms on different culture media. These do not overthrow, but simply 
mask, racial characters. 

On the other hand, Ravenel (1902, p. 45) says : — 

With these facts before us I do not think we are forcing a point in 
believing that it is at least possible for the bovine bacillus to become 
rapidly so changed in the body of man that it will show the cultural and 
pathogenic peculiarities which we find usually in cultures of human 
origin. 

In support of this view he quotes Nocard, who by introducing 
bovine and human bacilli into the peritoneal cavity in collodion 
sacs showed that in five to eight months both bovine and human 
bacilli acquired the cultural characteristics of the avian tubercle 
bacillus, and to a certain extent also its pathogenic action. 
Moller thought that he had so changed the human tubercle 
bacillus by passage through the blind worm for a year, that it 
grew best at 20 ° C. like the bacillus of fish tuberculosis. 

According to von Behring and De Jong passage through goats 
is able to change the bacillus of the Typus humanus into the 
Typus bovinus. Kossel is incredulous as to the transformations 
enumerated above, believing the results obtained to be due to 
inaccurate methods. He quotes as an analogous case the fact that 
before Koch discovered a method of separating bacteria and 
growing them in pure culture on solid media, examples of trans- 
formation of one species of bacteria into another were described, 
to be rejected on more accurate investigation. The experiments 
of Weber and Taute indicate the need of great caution. They 
have shown that the tubercle bacilli of fishes, mentioned above, 
are really acid-fast saprophytes derived from mud. Similarly 
in De Jong's experiment a goat was left for 3 J years after inocula- 
tion with tubercle bacilli of the human type before cultures were 
taken from it. The possibility under these circumstances of 
extraneous infection by bovine tuberculosis is considerable. 
Kossel, Weber, and Heuss passed bacilli of the human type 
through goats and cattle, and found that after five passages 
they still remained of the same type, although they had been 
in the goats up to 202 days and in the cattle up to 381 days. 

So far the evidence favours the view of a racial difference 
between tubercle bacilli of the bovine and those of the human 



136 THE PREVENTION OF TUBERCULOSIS 

types. Against this view is urged the fact that it is possible — in 
the words of Kossel (p. 1448) — to 

immunise cattle with the aid of tubercle bacilli of the Typus humanus 
against the bacilli of the Typus bovinus. This fact is adduced as proving 
that one is dealing with one and the same germ, on the ground that im- 
munity against a bacterium can only be produced by an identical micro- 
organism. Especially von Behring and Lorenz have emphasised this 
fact as conclusive. 

But Kossel then remarks : — 

On the other hand, it must be remembered that immunity in this 
direction is not equally specific in all species of bacteria. The fact that 
efficient tuberculin can be prepared from avian tubercle bacilli as well as 
from mammalian by itself suggests caution in applying to tuberculosis 
such experiences as have been gained with regard to immunity in other 
groups of bacteria. Furthermore, Beck observed that animals injected 
with acid-fast bacilli had become hypersensitive to tuberculin ; and Koch 
stated that by injection of tubercle bacilli into animals a serum could be 
produced which possessed agglutinating power, not only on tubercle bacilli, 
but also on saprophytic acid-fast bacilli. 

Finally, opinions are not wanting that the treatment of experimental 
animals with saprophytic acid-fast bacilli — that is, by micro-organisms 
in no way identical with tubercle bacilli — has a protective influence 
against the infection by tubercle bacilli (Moeller, Friedmann). I do 
not deny that the tubercle bacilli of the Typus humanus are nearly related 
to those of the Typus bovinus, and that their origin may be traced to a 
common stock j but these are considerations for which sufficient founda- 
tion is wanting. To-day we are dealing with two types that do not play 
the same part in the distribution of tuberculosis in animals and man, 
and therefore must not be confounded. It is not essential whether these 
types are defined as different species, or races, or varieties, for in any case 
they are not identical. 

The position of the problem is well summarised in the above 
extract from Kossel's report ; but on the same question the very 
elaborate and important experiments made on behalf of the 
English Royal Commission should also be consulted. 

We are now in a position to consider 

Von Behring's Views as to Human Tuberculosis.-— These 
are given in short in the extracts on p. 129. He holds that bovine 
tubercle bacilli, after long residence in human tissues from infancy 
onwards, become the source of adult phthisis, the chief cause of 
mortality from tuberculosis. Dr. Romer showed that true 
albumins penetrate unchanged the intestinal mucous membrane 
of new-born foals, calves, and small laboratory animals, without 



EVIDENCE OF BOVINE TUBERCULOSIS 137 

being converted into peptones as in adult animals. Following 
up this observation, von Behring found that similarly bacteria 
passed much more easily through the alimentary mucous mem- 
brane of new-born than of adult guinea-pigs. He concluded that 
the penetrability of infantile mucous membrane in artificially 
fed infants is the important cause of tuberculosis. He says : — 

The tubercle bacilli which gain access to the system through the ali- 
mentary tract in infancy constitute the important etiological factor in the 
production of the tuberculous infection which leads to consumption. . . . 

The virus of tuberculosis . . . creeps in most insidiously, all un- 
noticed, being in this respect analogous only to the virus of leprosy, of 
syphilis, or possibly of malaria in tropical countries. It may be months, 
years, or decades before the infection leads to manifest disease. This 
depends on the virulence of the virus . . . and on the number of bacilli 
introduced. 

Although von Behring states very lucidly the important fact 
of prolonged latency, his view that nearly all or all tuberculosis 
in man is due to a primary infection by the bovine bacillus cannot 
be accepted, for the following reasons : — 

(a) As inferred on p. 134, the results of the Royal Commission 
can be regarded only as proving that a relatively small proportion 
of human tuberculosis is of bovine type. 

(b) The evidence given above points against the conclusion 
that transformation of Tyftus bovinus into Typus humanus occurs ; 
so that, until further investigations have been made, von Behring 
cannot justifiably explain the relatively small proportion of the 
bovine type as being due to transformation in the body into the 
human type. 

(c) Doubtless other observers have, like myself, collected a 
number of cases of fatal infantile tuberculosis where human milk 
alone had been given. The element of doubt attaching to 
tubercle bacilli of uncertain or variable type (Group III. p. 127) 
mentioned in the report of the Royal Commission (1907) is 
summarised in the following extract (par. 63) from that report : — 

Should it be proved that the cases in question were due to an ad- 
mixture with the bacilli of human source of a few bacilli of bovine source, 
the two kinds always remaining distinct the one from the other and 
never becoming changed the one into the other, we should have no need 
to enlarge appreciably our conception of the extent to which the human 
body is subject to bovine tuberculosis. Such cases of admixture must 
be few and their effect slight ; bovine tuberculosis in the human body 



138 THE PREVENTION OF TUBERCULOSIS 

would practically be limited to cases such as those which furnish Group 
I. (p. 126). 

Should, however, it be conclusively proved that a eugonic x bacillus 
of low virulence may be modified under certain conditions into a dysgonic 
bacillus of high virulence and vice versa, our views as to the relation of 
human to bovine tuberculosis must be very different. Such a conclusion 
would lead to the following view. Bacilli from a bovine source entering 
a human body in scanty numbers may become lodged there without 
immediately provoking a generalised progressive tuberculosis. During 
their sojourn there they may become modified into eugonic bacilli of 
low virulence ; and they may then give rise either to a limited tuberculosis 
only or, under the influence of certain conditions, to a generalised pro- 
gressive tuberculosis. For some time after the change they may remain 
unstable and capable of reverting to their bovine character under changed 
conditions, when subjected for instance to the influence of bovine tissues 
as in the passage experiments. Or after a long stay in the human body 
their character may become so fixed that they cannot be distinguished 
from bacilli conveyed directly from man to man. 

It is on account of the far-reaching bearings of the conclusion that we 
are unwilling to make any statement at all premature. 

We may take this opportunity of pointing out that time is an essential 
factor in dealing with a disease of so chronic a nature as tuberculosis. 
Some of its problems, such for instance as the possible change in virulence 
and other characters of the virus obtained from one kind of animal by 
repeated passage from animal to animal of another species, can only be 
settled after constant observations extending over a long period of time. 

From a survey of the evidence we must conclude that the 
conversion of Typus bovinus into Typus humanus during the 
lifetime of a single person and in his tissues is unproved. The 
third of the three alternatives given in Chapter XVI., pp. 128-129 
fits in best with all the facts at present known; and we 
are justified, in view of the balance of evidence, in concluding 
that (1) both Typus bovinus and Typus humanus are competent 
to produce tuberculosis in the human being ; (2) both forms of 
the disease have been identified in man (p. 126) ; (3) the bovine 
type is more common in children than in adults ; (4) the bovine 
type retains its special characters even in the human subject ; 
and (5) tuberculosis of bovine origin is much less frequent in the 
human subject than tuberculosis of human origin. 

Conclusions (1), (2), and (3) are established with certainty; 
(4) and (5) are probable. 

1 A eugonic bacillus is one which grows readily, a dysgonic bacillus one which 
grows with difficulty on artificial media. 



CHAPTER XVIII 

TUBERCULOSIS FROM MEAT AND FROM MILK AND 
OTHER DAIRY PRODUCTS 

IN this chapter it is assumed that a certain — probably a 
relatively small — proportion of human tuberculosis is 
caused by tubercle bacilli of the bovine type ; and it is 
proposed to consider the extent of the disease in cattle and the 
frequency with which tubercle bacilli are found in milk and other 
dairy products. 

Amount of Tuberculosis in Cattle. — According to the 
evidence of Mr. (now Sir) T. H. Elliott, Secretary to the Board of 
Agriculture, before the Royal Commission on Tuberculosis, 1898, 
at least 20 per cent, of the cows in this country are tuberculous. 
Delepine (1899) found that in farms which had careful sanitation 
the proportion varied according to age from 20 to 31 per cent. 
in milch cows, and that on some farms from three-fourths to all of 
the cows were affected. MacFadyean (1901) states : " We know 
that about 30 per cent, of all the cows giving milk in this country 
are tuberculous in some degree." This undoubtedly implies a 
most unsatisfactory state of things ; and if tuberculosis is easily 
communicable to man from tuberculous cattle, the wonder is 
not that the disease is common in man, but that it is not much 
more common. 

Tuberculous cattle might be a source of human tuberculosis 
(1) by dust or spray infection from cattle suffering from lung 
disease ; (2) by the eating or handling of the flesh of tuberculous 
cattle ; or (3) by consuming milk or some milk-product derived 
from tuberculous cows. 

There is no evidence on the first point, and it may be 
ignored, as an unlikely or at least an uncommon source of 
infection. 

Tuberculous Flesh. — Butchers and others dressing tuber- 
culous animals may receive accidental inoculations through 

139 



140 THE PREVENTION OF TUBERCULOSIS 

wounds ; but the development of fatal tuberculosis after such 
accidents is excessively rare. 

The flesh from tuberculous cattle is undoubtedly sometimes 
infective. Much evidence on this point was collected by the 
English Royal Commission of 1895. It was shown that uncooked 
tuberculous material given as food to guinea-pigs, calves, pigs, and 
cats produced tuberculosis. In " joints " of meat it is excep- 
tional to find tuberculous nodules or other evidence of disease, 
though to a practised eye the " stripping " of the pleura lining 
the ribs gives rise to suspicion of tuberculous " grapes " removed 
in the dressing of the animal. S. Martin in his experiments 
for the above Commission frequently produced tuberculosis by 
inoculating or feeding animals with flesh from tuberculous cattle, 
" in which no tubercle could be detected by his ocular tests." 
This led him to consider the "real and considerable danger" of 
the meat becoming contaminated by the butcher's hands, knives, 
and cloths, which had been previously in contact with tuberculous 
lesions in the animal. " The greater the amount of tubercle 
there is in the cow " the more likely " is the sticky caseous 
matter to get smeared over the carcass." Thus he failed to pro- 
duce tuberculous disease by feeding animals on meat from cows 
with mild or moderate tuberculosis, though inoculation of test 
animals might be successful ; while feeding with meat from 
cows with advanced or generalised tuberculosis succeeded in 
producing tuberculosis. 

The main tuberculous lesions in cattle are found in the organs, 
membranes, and glands; but seldom in the flesh or meat sub- 
stance. Naked-eye evidence of disease has therefore usually 
been removed from the dressed carcass, with the possible excep- 
tion of a few pea-like tubercles internal to the ribs or about the 
diaphragm, or a few small glands in certain " joints." As will be 
seen subsequently, cooking processes may with certain exceptions 
protect the adult (p. 404) ; but meat juice made from tuberculous 
flesh is distinctly dangerous. 

The fact that during a period in which the consumption of 
meat has greatly increased, human tuberculosis has greatly 
declined does not favour the view that tuberculous meat has 
played a large part in its causation. I am not aware of any 
evidence that the proportion of tuberculous cattle is markedly 
less than formerly. 



TUBERCULOSIS FROM DAIRY PRODUCTS 141 

Tuberculous Milk. — The evidence of the pathogenicity of 
cows' milk to a dangerous extent is much clearer than that of 
cows' flesh. Thus S. Martin reporting to the same Commission 
(p. 16) found that out of 15 tuberculous cows 8 had healthy 
udders ; 2 had udder disease, which was proved after slaughter 
not to be tuberculous ; and the remaining 5 had tuberculous 
udder disease. With the milk from these cows, tests were made 
with the following results (Report, p. 16) : — 

(a) The 8 tuberculous cows which had healthy udders showed him no 
tubercle bacilli whatever in the milk of any one of them ; 41 test animals 
fed with their milk remained perfectly free from tuberculous disease ; 28 
test animals inoculated with their milk also remained quite free from 
tuberculous disease. 

(5) The 2 tuberculous cows which had udder disease, found post- 
mortem not to be tuberculous in nature, showed him no tubercle bacilli 
in their milk. Three test animals, fed with their milk and 14 other test 
animals inoculated with their milk, remained, all of them, perfectly 
free from tuberculous disease. 

(c) Of the 5 tuberculous cows which had udder disease, found post- 
mortem to be of tuberculous nature, 3 showed him tubercle bacilli 
in their milk. He could not find tubercle bacilli in the milk of the 
other 2. With milk from the 3 cows, 15 test animals were fed, with the 
result of producing tuberculosis in every one of them. With milk from 
one or other of the same 3 cows, 1 3 test animals were inoculated, with 
the result of all 1 3 acquiring tuberculous disease. The milk of the fourth 
cow (one of those which had not shown tubercle bacilli) was used to feed 
10 test animals, and produced tuberculosis in 4 of them. Inoculated 
into 6 test animals, all of them became tuberculous. The milk of the 
fifth cow (in which also no tubercle bacilli had been seen) was used to 
feed 2 animals, but without result. Yet when it was used to inoculate 
2 other animals, both of them acquired tuberculous disease. 

(d) It remains to note these tests as applied to the milk of the two 
cows found after slaughter to be suffering under another disease, but not 
tubercle. The results were : no tubercle bacilli found in the milk of 
these cows ; inoculated into 17 test animals, it did not produce tuber- 
culosis in any one of them ; milk from one of the cows, however, in some 
test animals gave rise to various abscesses. 

The Report of this Commission goes on to say (p. 17) that 

according to our experience, then, the condition required for ensuring 
to the milk of tuberculous cows the ability to produce tuberculosis in 
the consumers of their milk, is tuberculous disease of the cow affecting 
the udder. It should be noted that this affection of the udder is not 
peculiar to tuberculosis in an advanced stage, but may be found also 
in mild cases. 



142 THE PREVENTION OF TUBERCULOSIS 

All are agreed that when there is tuberculosis of the udder 
the milk is found to be dangerously infectious, and so likewise 
are all products of such milk, as butter, skimmed milk, butter- 
milk, cheese. Thus the report of the same Royal Commission 
states : " The milk of cows with tuberculosis of the udder 
possesses a virulence which can only be described as extra- 
ordinary " (par. 61). It is also ominous that " the spread of 
tubercle in the udder goes on with most alarming rapidity." 
Sims Woodhead remarks (par. 62), " I have noticed on several 
occasions, during the interval between fortnightly inspections 
carried on along with a veterinary surgeon, that the disease had 
become distinctly developed. It may be, of course, that the 
early evidence has been overlooked at the previous inspection, 
but whether this is the case or not, the spread of the disease was 
so rapid as to afford very good ground for alarm. The very 
absence of any definite sign in the earlier stage is one of the greatest 
dangers of this condition." 

Professor (now Sir) J. MacFadyean (1901, p. 84) points out in 
the following remarks, 

not every cow that is tuberculous gives milk containing tubercle bacilli. 
It is true that opinions with regard to this point are not absolutely unani- 
mous, but there is ample evidence to justify the assertion that, as a rule, 
the milk is not dangerous until the udder itself becomes diseased. The 
experiments pointing to an opposite conclusion form only a small minority, 
and the results obtained in most of them were probably due to careless- 
ness on the part of the experimenter. In a few of the cases in which 
the milk of an apparently healthy udder was found to be infective it is 
probable that the gland tissue was in reality diseased, though not to 
an extent discoverable without microscopic examination. The important 
question, therefore, is not what proportion of milch cows are tuberculous, 
but what proportion of them have tuberculous udders. Some authorities 
have estimated this to be as high as 10 per cent., but the proportion is 
certainly much less than that in Great Britain. My own experience 
leads me to think that about 2 per cent, of the cows in the milking herds 
in this country are thus affected. Now, the milk secreted by a tuber- 
culous udder always contains tubercle bacilli, and it sometimes contains 
enormous numbers of them, and when these facts are apprehended one 
begins to realise the seriousness of the danger to which, in the present 
state of affairs, those who drink uncooked milk are exposed. But there 
are one or two considerations that make the danger greater than the 
mere statement of the number of cows affected would at first sight in- 
dicate. In the first place, the udder disease is not attended by any pain 
or tenderness in milking, and the milk for a considerable time after the 
udder has become manifestly diseased may appear quite wholesome, 



TUBERCULOSIS FROM DAIRY PRODUCTS 143 

though in reality it is charged with the germs of tuberculosis. It there- 
fore often happens that the gravity of the condition is not realised by the 
milker or the owner of the cow, and the milk continues to be sold for 
human consumption. There is scarcely any room for doubt that if it 
were sold and consumed unmixed with other milk some of the persons 
partaking of it would become infected. In practice it is usually mixed 
with the milk from other cows that have healthy udders, and thus the 
germs are distributed among a large number of persons. Even tuber- 
culous milk that has been thus much diluted may prove infective, but the 
danger to the individual consumer is in inverse proportion to the degree 
of dilution. Since about one cow in 50 is the subject of tuberculosis 
of the udder, and the average number of cows in the milking herds of 
this country is less than 50, it follows that the majority of dairies and 
farms supply milk that is free from tubercle bacilli, or at least does not 
contain any derived from this source. On the other hand, when the 
infected material is present, it operates with the greatest intensity in 
the milk of single cows and in the mixed milk from small herds. 



By other observers the percentage of milch cows with tuber- 
culous udders is put somewhat higher. Thus Professor Delepine 
puts it at 37 per cent. (1899, p. 19). 

Muller (1905) found that the udder was tuberculous in from 
n to 37 per cent, of the tuberculous cows slaughtered in Saxony 
during the years 1888-97, and in r6 per cent, of the tuberculous 
cows in the whole of Germany. In Denmark in 1901-02 the 
number of cases in which tuberculosis of the udder was detected 
and the cows subsequently slaughtered was 584, or 0*55 per 1000 
of the total stock. In the experience of the East Prussian Herd- 
book Society, a half-yearly examination of the herds and a 
quarterly examination of the milk, implying a very thorough 
control, only showed 62 cases of tuberculous udder in 15,000 
cattle, or 0*4 per cent. 

Are Tubercle Bacilli found in Cows' Milk in the 
Absence of Tuberculous Udder Disease ? — From the experi- 
ments of the English Royal Commission already quoted, it 
would be inferred that this question must be answered in the 
negative, or that tubercle bacilli when found are too few to be 
dangerous. Other experimenters have published results con- 
tradictory to these, tubercle bacilli being found in milk when 
udder disease was absent in cows suffering from clinical tuber- 
culosis, or even when cows had no obvious evidence of tuber- 
culosis but reacted to the tuberculin test. These results have 
failed to be substantiated. Thus Ostertag examined 77 such 



i 4 4 THE PREVENTION OF TUBERCULOSIS 

cows without finding tubercle bacilli in the milk after testing 
it microscopically, by inoculation, and by prolonged feeding 
experiments. Ascher, M'Weeney, and Strenstrom obtained like 
results. The latter concluded that tubercle bacilli found in the 
milk by observers obtaining different results must have gained 
access to it during milking. This may have been derived from 
tuberculous milkers ; but Ebers regards the very common 
fouling of the milk with particles of cow-dung as the source of 
tubercle bacilli. Tuberculous cows after coughing commonly 
swallow their expectoration, which would subsequently appear 
in the faeces. This evidence has been more recently confirmed. 

The detailed results of the East Prussian Herdbook Society 
are interesting in this connection. Samples of milk were taken 
from the total milk of 1596 herds, and tubercle bacilli were found 
in 97 samples. In 59 of these tuberculous udders were dis- 
covered, and in the other instances there was reason to believe 
that contamination of the milk after leaving the animal had 
occurred. The above experiment represented the milk of about 
20,000 cows, and it may be assumed in accordance with average 
experience that 6000 to 7000 of these were tuberculous ; and 
yet in 1499 out of 1596 herds no tubercle bacilli were found in 
the milk. The evidence that contamination of the milk is most 
often due to udder disease is very strong, though contamination 
by cows' dung or from milkers also occurs, and cannot be left out 
of count. 

Proportion of Infective Milk in Mixed Supplies to the 
Public. — The preceding experience of the Herdbook Society 
must be regarded as exceptional, in the fewness of the herds 
containing infective milk. English experience shows that a very 
large percentage of ordinary mixed milk contains tubercle bacilli. 
Thus Delepine (1898) found tubercle bacilli in 22 out of 125, or 
17-6 per cent., of samples of milk from country dairy-farms 
collected at railway stations in Liverpool and Manchester. 
Kanthack and Sladen found that specimens of 9 dairies were 
infected out of 16 examined. Woodhead and Wood found 
virulent tubercle bacilli in 5 out of 50 specimens, and Rabino- 
witsch and Kempner in 7 out of 25 samples in Berlin. Taking 
these as fair samples of a much larger number of examinations, 
it would appear that about 20 per cent, of the mixed milk supplied 
to towns contains living tubercle bacilli. 



TUBERCULOSIS FROM DAIRY PRODUCTS 145 

Tubercle Bacilli in other Dairy Products. — Many 
observations have been made and tubercle bacilli have been 
found. It is not unlikely that the earlier observations over- 
stated the facts, acid-fast bacilli simulating the tubercle bacillus 
having been confused with it. There can be no doubt, however, 
that when milk contains tubercle bacilli, cream, butter, cheese, 
skimmed milk, and buttermilk are likewise infective. Margarine 
may also contain tubercle bacilli, introduced with the milk 
which is blended with it. Cream is likely to be particularly 
dangerous, as the cream in rising is found to carry an excessive 
proportion of the bacilli with it. The feeding of calves and 
pigs on skimmed milk, buttermilk, whey, and the refuse collected 
on centrifuges is a common source of tuberculosis in them. The 
horse has also been shown, especially in Denmark, to be very 
liable to tuberculosis when fed on milk or its products. Pigs 
are rarely infected from one another, but mainly by their food. 
Tuberculosis is very prevalent in pigs only when a large dairy 
industry is carried on. The slaughter-house reports of Copen- 
hagen for 1897 show that the proportion of tuberculous pigs 
varied from 3 to 14 per cent. ; while in Bavaria, in which there 
is only a small dairy industry, only 0*2 to 0-4 per cent, of the 
pigs slaughtered in 1896-1900 were tuberculous. In Denmark 
pig tuberculosis has become much less frequent since it has been 
made compulsory to heat separated milk before it is returned 
from the creameries. 



CHAPTER XIX 
DOMESTIC INFECTION 

TUBERCULOSIS is undoubtedly caused most often by 
domestic infection. Koch (1906, p. 1449) says that 
tuberculosis " has been frankly and justly called a 
dwelling disease " ; while Biermer goes further and describes it 
as essentially a bedroom disease. There is little doubt that its 
infection is chiefly acquired in bedrooms. Industrial conditions, 
although an important source of infection, probably act to an 
even greater extent by removing or paralysing influences inhibi- 
tory to infection, thus opening the door to infection or stirring 
into activity infective material latent in the tissues. 

In treating of domestic infection it is necessary to distinguish 
between indirect or mediate and direct or immediate infection. 
The influence of overcrowding is complex, and is concerned 
partly with infection and partly with the conditions of imperfect 
sanitation usually associated with overcrowding. 

Infection due to the Dwelling proper. — The experi- 
mental results of Cornet and others (p. 98) show that tubercle 
bacilli are present, but only in the immediate environment of 
consumptives. Given that a house has become infected through 
the uncleanly habits of a consumptive who has recently lived 
and possibly died in it, there are the great limitations to infection 
already enumerated on pp. 101-105. Although it is in the highest 
degree desirable that such a house should be efficiently cleansed 
and disinfected, it is unlikely to form a large element in the pro- 
duction of phthisis by domestic infection. It may be, however, 
that apart from this additional source of infection, evil conditions 
of housing lower vitality, diminish the resistance to infection, 
and thus increase the amount of tuberculosis among the poor. 
This point is further discussed on p. 192. Such influences 
undoubtedly favour tuberculosis by hastening the occurrence 

of infection, and no preventive measures can be regarded as 

146 



DOMESTIC INFECTION 



147 



efficient and complete which do not vigorously attack and re- 
move housing defects. It is possible, however, to obtain some 
indications of the chief agency which causes the dissemination 
of tuberculosis in overcrowded quarters. 

Overcrowding. — There is abundant statistical evidence of 
the close association between overcrowding and excessive 
mortality from phthisis. Thus Sir Shirley Murphy has shown 
that in London the death-rate from phthisis steadily increases 
with the proportion of the total population living more than two 
in a room, in tenements comprising less than five rooms. This 
experience is summarised in the following table : — 

Table XXIV 



London. — Proportion of Population living 

more than Two in a Room 
(in Tenements of less than Five Rooms). 



London. — Average Annual Death-rate 

from Phthisis per 100,000 of Population, 

1894-98. 



Districts with under 10 


oer 


cent. 




» » 10-15 




j> 




5> 5» I5-20 




5» 




20-25 




J5 




25-30 




>5 




30-35 




5J 




,, ,, over 35 




JJ 





III 

144 
161 
177 

209 

231 
259 



When the same facts are subdivided according to ages of 
the patients dying from phthisis, it is found that the excess of 
the death-rate from this disease in the most overcrowded 
districts is greatest at the ages at which the mortality from it is 
heaviest. Sir Shirley Murphy in commenting on the table 
summarised above says (Ann. Rep. 1898, p. 46) : — 

There is obviously a relation between the amount of overcrowding 
and the phthisis death-rate. The figures do not, however, suffice to 
show whether the overcrowding caused phthisis, or whether the disease, 
by adding to family expenditure or by diminishing the wage-earning 
power, left less money available for rent and thus brought about the over- 
crowding, or whether again overcrowding is associated with some other 
condition or conditions which are favourable to disease. In all prob- 
ability all these circumstances have tended to produce the results shown 
in the table. 

There is a further difficulty in accepting the above figures 
as completely satisfactory evidence that crowding is a main 
influence in causing tuberculosis. The house where a person 



148 



THE PREVENTION OF TUBERCULOSIS 



dies of this disease is not necessarily the house in which he ac- 
quired it. In view of the frequent changes of house among the 
poor, and of the protracted duration of phthisis, the coincidence 
between the two is probably exceptional. The usual course of 
events is for a person who becomes consumptive to drift, owing 
to his impaired working powers, from the class of skilled to that 
of unskilled and casual labour ; and with each step downwards 
his housing conditions deteriorate to a corresponding degree. 

In Part II. pp. 220 to 229 a comparison of different coun- 
tries shows that the death-rate from phthisis does not vary in 
accordance with their relative position as to sanitation and 
housing, whether the different countries are compared with each 
other, or whether the death-rate and housing conditions of 
the same country are compared at different times. 

The following additional evidence, quoted from a recent 
address by the writer (1907), bears on the same point. The 
figures as to housing are taken from a paper by Sir W. Matheson, 
Registrar-General of Ireland: — 

Table XXIVa 







med 
ive or 
:h in 
nts 


; in 
ents, 
e 

100 
Lion. 


S 
So 8 




: of One-roo 
nts Per Cen 
[ Dwellings 
enements. 


: of One-roo 
ts having Fi 
ccupants eac 
100 Teneme 
all Classes. 


:r of Persons 
med Tenem 
Five or moi 
nts in every 
otal Populai 


Death-rate 
is, per ioo,c 
, in the Thr 
rs 1 900- 1 -2, 




imbei 

neme 

Total 

T 


•2 1° fro 


umbc- 
e-roo 
with 
:cupa 
:heT 


srage 

hthis 

iving 

Yea 








*o 0^ 


< 


Dublin 


3670 


8*69 


io*6i 


329 


Belfast 








i*oo 


0*09 


o*io 


313 


London 








14*66 


o'57 


0*70 


171 


Liverpool 








6*14 


0*22 


0*24 


190 


Manchester 








1-90 


0*04 


0*05 


208 


Edinburgh 








16-98 


i*8o 


2'33 


164 


Glasgow 








26*11 


4*28 


5-24 


177 



Thus in Glasgow, which has 26 times as large a proportion 
of one-roomed tenement dwellings as Belfast, and 52 times as 
many persons in its one-roomed tenements with 5 or more oc- 
cupants, the death-rate from phthisis instead of being higher 
is 43 per cent, lower than that of Belfast. This does not imply 
that in a given town the death-rate from phthisis is not higher 



DOMESTIC INFECTION 149 

in the smaller and more overcrowded tenements. Abundant 
statistics show this to be the case. But it is clear from the 
above table that size of dwelling or even degree of overcrowding 
may be overshadowed by the effect of other influences. 

It may be taken as an axiom that overcrowding favours 
tuberculosis. Doubtless there is more than one modus operandi in 
bringing about this result. Two things, however, are certain : — 
(a) Tuberculosis cannot be produced, however strong may 
be the favouring circumstances, unless its infection is received ; 
and (b) although, as seen above, the death-rate from phthisis in 
a given community is always greater in proportion to the 
amount of overcrowding, there is, when different countries or 
different cities are compared with each other, no direct relation 
between the amount of overcrowding and the amount of 
phthisis. 

It will be subsequently seen that a given amount of over- 
crowding with a large amount of institutional segregation of 
consumptives is associated with less phthisis than when over- 
crowding is less but accompanied by only a small amount of 
institutional segregation of consumptives (pp. 224 to 295). We are 
justified in concluding therefore, that the quickest way to diminish 
the risks of overcrowding is to favour by every means of persuasion 
the removal of the sick from among the healthy. This should, of 
course, be accompanied by strenuous endeavour to diminish over- 
crowding, apart from the question of such removal. 

Family Infection. — The facts already given indicate almost 
sufficiently the risks of family life when one member is a con- 
sumptive, though they also happily indicate with what ease and 
how simply these dangers may be avoided. The histories of 
family infection given on pp. 64-68 are examples of the 
conditions under which tuberculosis spreads. 

It is sufficiently clear that young children are particularly 
prone to be infected, partly because they are more caressed, and 
possibly also because they are more susceptible than their elders. 
Girls are more exposed to infection than boys (see p. 171). 
The most intimate relationship in family life is that of husband 
and wife, and the evidence as to infection between these may 
therefore be examined. 

Infection in Married Life. — When a married man or 
woman is consumptive, is the proportion of instances in which 



150 



THE PREVENTION OF TUBERCULOSIS 



the partner is also consumptive greater than the average for 
persons of the same age and sex apart from married life ? There 
cannot be said to be sufficiently full evidence to settle this point. 
The following table is given to show the varying percentages 
stated by different collectors of statistics : — 



Table XXV 
Nu?nber of Married Couples with One or Both Consumptive 





- r& 




<u 






C/5 "i3 


in 


_ J-< 






M o 6 




.S 2 « 






3 ., '-3 


"S ou 






Authority. 


u£s 




Bog 


Quoted from — 




No. oi 

with or 

Consi 


No. 0; 

wit 

Consi 


Perce 

which 

Cons; 




Brehmer 


159 


19 


ii'9 


Cornet On Tuberculosis 
(Nothnagel), p. 265. 


Haupt . 


260 


30 


ii*5 


>» 


Cornet . 


594 


135 


227 


»> 


Schuyder 


844 


32 


3-8 


Lancet, Sept. 19, 189 1. 


Rivers . 


84 


6 


7«i 


K. Pearson, 1907. 


Weber . 


80 


19 


237 


Weber, 1874. 



Clearly figures giving such discrepant percentages cannot 
be comparable. Observations of supposed infection between 
married couples or its absence are trustworthy only if they 
accurately state the length of the married life of the couples 
under observation, and the subsequent history through life of 
the surviving partner. In other words, to arrive at the truth 
one must have the complete life-experience of the married 
couples, and a sufficient number of these to avoid accidental 
errors. I do not think that most of the observations tabulated 
above will bear this test. Even when these tests are satisfied, 
it has to be remembered that frequently patients having had 
phthisis die as the result of other diseases. The long latency of 
phthisis in a considerable proportion of the total cases is one of 
the most serious difficulties in the more detailed and elaborate 
investigation on this point that is needed. 

Even when allowance is made for coincidence, the following 
instance of apparent communication of pulmonary tuberculosis 
by a husband to successive wives, given by Sir Hermann Weber 
(1874, p. 144), is sufficiently striking to deserve reproduction : — 



DOMESTIC INFECTION 151 

A. B. lost his mother, two brothers, and a sister from pulmonary tuber- 
culosis. He had haemoptysis at the age of 20. He then became a sailor. 
He married when 27 years old, and was then quite well. 

His first wife came of a healthy family, and had good health till to- 
wards the end of her third pregnancy, and she died after her confinement. 

After a year he married again, his wife being apparently healthy. 
She developed a cough after a year of married life, and died of pulmonary 
tuberculosis. 

His third wife was 25 years old when he married her. She came of 
an exceptionally healthy family. In her second pregnancy she began 
to cough, and died after the second confinement. 

His fourth wife, who was 23 years old when he married her, and who 
had come of a healthy family, began 13 months later, i.e. 3 months after 
her first confinement, with a cough, and died later of phthisis. 

A. B. did not marry again. When examined in 1854 after the death 
of his third wife he showed evidence of old pulmonary tuberculosis. He 
died in 1871 of this disease, and an autopsy showed old cicatrised disease, 
and recent tuberculosis. 

Dr. Weber states that in 29 marriages between consumptive 
wives and healthy husbands only one husband became con- 
sumptive ; while in 51 marriages between consumptive husbands 
and healthy wives 18 wives became consumptive. 

There is, I think, in view of our general knowledge of tuber- 
culosis, no reasonable doubt that the close intimacy of married 
life has, in the absence of intelligent precautions, been a not 
infrequent cause of phthisis when one partner is already affected. 
The wife is more likely to suffer from her diseased husband, than 
the husband from his wife; as the wife has more protracted 
opportunities of receiving infection, especially in the later stages 
of the disease. 



CHAPTER XX 
INFECTION IN ATTENDANCE ON THE SICK 

THE majority of consumptives, when ill enough to require 
nursing, are nursed by their own relatives. The degree to 
which infection occurs among them has already been 
discussed (p. 149). In view of the evidence already given, and 
that cited in Part II., there can, I think, be little difficulty in 
agreeing that the home-treatment of advanced consumptives 
in crowded dwellings, in which the necessary precautions cannot 
be taken, is a predominant cause of the continued spread of 
tuberculosis. It still remains to discuss the possibilities of 
infection of nurses and other attendants in the institutional 
treatment of phthisis, and the possibilities of infection of doctors 
who attend consumptive patients at their homes or in institutions. 

The most carefully investigated experiences are those of the 
Brompton Hospital and of the Victoria Park Hospital for Dis- 
eases of the Chest, the former investigated by Drs. Cotton and 
Theodore Williams, the latter by Dr. Andrew. Wilson Fox (1891, 
P- 563) summarises these experiences in the table on the follow- 
ing page. 

In the Brompton returns the number of nurses and servants 
is given only for 20 years, the deaths for 36 years. It appears 
that, so far as could be ascertained, during 36 years only one 
death from phthisis occurred among the physicians, and only 
five cases among the nurses during or subsequent to their work 
in the hospital. The results for the Victoria Park Hospital 
are somewhat similar. It is very difficult to analyse this evidence. 
It is very scanty. It is not certain how thoroughly the subse- 
quent history of workers in these hospitals was traced. It is 
likely that such workers as had died were less completely traced 
than those still alive. Again, we do not know the total dura- 
tion of hospital work of the above persons. If we assume that, 
including servants, it averaged two years, then among the 377 



INFECTION IN ATTENDANCE ON THE SICK 153 

vvorkers in the Brompton Hospital the annual number of cases 
of phthisis among the staff while still at the hospital (exclud- 
ing deaths) was about 1 in 94, or including cases developing 
later was 1 in 37, which is much higher than the estimated 
number in the general population (p. 63). I do not think, 
however, that the evidence as collected is sufficiently accurate 
to bear such a comparison as this, and it is made only to in- 



Table XXVI 





Brompton. 


Victoria Park. 




Number of Cases 


a 








a 




d 


of Phthisis. 


5tt 


<L> 




cS 






22 tn 


CO 


3 .si 


1/3 oi 


CO 












a ■* 

1 & 


1.3 


>> 

cd 

00 

g 


<u 
cr 


"£! Co 


O 
hi 

<u 

a 

3 








£ p 


< 


3 

Q 


co 


H 


fe 


£ 


O 
H 


Resident Medical Officer . 


4 










12 


I 


I 


Clinical Assistants . 


!5o 


I 


1 


6 


5 


51 


3 


3 


Matron .... 


6 










4 






Nurses .... 
Servants .... 


IOl(?) 
32(?) 




i(?) 


4 


5(?) 


J255 


i(?) 


iff) 


Porters .... 


20 










34 


1 


1 


Secretary and Clerks 


9 




3(?) 






3 


1 


1 


Dispensers 


22 




3 


2 


3 


7 






Chaplain .... 


4 










5 






Physicians and Assistant 


















Physicians 

Total 


29 








1 


3i 


1 


i(?) 


377 


I 


8 


12 


14 


402 


8 (7?) 


8(7?) 



dicate that the data, if completely accurate, do not contra- 
indicate a considerable possibility of infection among the staff 
of these hospitals, and do not, as commonly supposed, offer 
any presumption of freedom from infection. 

A similar remark applies to Dr. Robertson's figures for the 
Ventnor Hospital for Consumption (Bulstrode, 1903, p. 76). 
During the 22 years 1881-1902, 15,500 phthisical patients were 
treated in this hospital, and during the same period 62 officers, 
208 nurses, 407 housemaids, and 1 charwoman — total, 678 
— were engaged in the institution. None of the officers have 
contracted tuberculosis. Six nurses, of whom two died, have 



154 THE PREVENTION OF TUBERCULOSIS 

had phthisis, but apparently three had the disease on admission. 
The records for housemaids are not very definite. Here, again, 
one would wish for exact information as to the length of service 
and of the subsequent period over which each member of the 
staff could be traced. In view of what has been said about 
prolonged latency of tuberculosis (p. 73), this is an essential 
condition of an accurate investigation. 

The above experiences are usually quoted as instances of 
non-infection in hospitals. They should rather be described 
as examples of investigations, in which the data are, possibly 
owing to insuperable difficulties, incomplete and insufficient 
to justify any dogmatic statement. 

In attempting to ascertain the true inwardness of the statistics 
of hospital staffs relating to phthisis, generally quoted, it is not 
suggested that the nursing of consumptives under the hospital 
conditions of to-day, including the adoption of the best pre- 
cautionary measures, involves considerable risk. 

All that is suggested is that the danger is to a definite extent 
greater than that for the general population, though much less 
so than formerly. In all well-regulated workhouse infirmaries, 
hospitals, and sanatoria, absolute cleanliness is maintained ; and 
soiled handkerchiefs and the contents of spittoons are pre- 
vented from becoming sources of infection. The chief remain- 
ing source of danger is direct infection, which the careful nurse 
avoids. The conditions are altogether different from those of 
the wife who attends on the consumptive breadwinner. She 
is in intimate personal contact with the patient day and 
night ; may have insufficient rest ; is overfatigued, and often 
underfed. Mental anxiety still further lowers her powers of 
resistance to infection. It is not strange, therefore, if she falls 
a victim, while the hospital nurse escapes. There is little diffi- 
culty in agreeing with Koch's summing up of this subject (1906, 
p. 1449) :— 

In hospitals for pulmonary phthisis it is in certain circumstances 
possible that no cases of infection occur among the attendants, or at 
any rate so few that in former times it was thought necessary to regard 
this as a proof of the non-contagiousness of tuberculosis. But if one 
examines such cases more carefully there are good reasons for the apparent 
non-contagiousness. It then appears that the patients in question are 
people who are very cautious about their sputum, see to the cleanliness 
of their dwellings and clothing, and live in copiously aired and lighted 



INFECTION IN ATTENDANCE ON THE SICK 155 



rooms, so that the germs that get into the air can be swiftly swept away 
by the current or killed by the light. If these conditions are not fulfilled, 
there is no lack of infection even in hospitals and the dwellings of the 
well-to-do, as experience teaches daily. And it becomes the more frequent 
the more uncleanly the patients are as regards their sputum, the more 
lack there is of light and air, and the more closely crowded together the 
sick live with the hale. The danger of infection becomes especially great 
when healthy people have to sleep in the same rooms with sick people, 
and even, as unfortunately still frequently happens among the poor, in 
the same bed. This kind of infection has struck attentive observers 
as so important that tuberculosis has been frankly and justly called a 
dwelling disease. 

Doctors are not exposed to infection so often, or for such 
long periods, as nurses. They have no difficulty in their work 
in escaping direct infection from coughing, and one would not 
expect to have among them any definite evidence of risks 
markedly greater than those of the general community, of acquir- 
ing tuberculosis. The data in Table XXVI. are too scanty 
to form the basis of a sound conclusion. The official occupa- 
tional figures given by Dr. Tatham in the Decennial Supplement 
of the Registrar-General's Report (1881-90) offer a much wider 
basis of induction. In these figures the death-rate from all 
causes and from certain specified causes among males, aged 
25-65, are compared in groups, whose composition as to age 
is identical. In these groups the number of the general popu- 
lation that would furnish 1000 total deaths from all causes 
(comparative mortality figure) is found to furnish 966 deaths 
among doctors, 821 among lawyers, and 533 among the clergy. 
Ogle in 1871-80 found that the death-rate from phthisis and 
from respiratory diseases was lower among doctors than among 
the general male population. The figures for 1881-90 confirm 
this result, as shown in the following table :— 

Table XXVII 

Comparative Mortality Figures of Males aged 25-65, during 1881-90, 

in Different Occupations, from 





All Causes. 


Phthisis. 


Bronchitis. 


Pneumonia. 


Influenza. 


All Males 


1000 


192 


88 


107 


33 


All occupied 










1 


Males 


953 


185 


88 


105 


34 


Clergy . 


533 


67 


11 


45 


36 


Doctors . 


966 


105 


12 


93 


5i 



156 THE PREVENTION OF TUBERCULOSIS 

Doctors have a much lower death-rate from phthisis than 
the average male population. It will be observed that their 
death-rate from influenza is excessive, and the comparison 
is interesting, illustrating as it does the much more rapid and 
more intense infectivity of the latter disease. 



CHAPTER XXI 
INDUSTRIAL INFECTION 

IN considering the possibilities of infection in various 
industries, the general considerations already emphasised 
must be borne in mind. (i) Prolonged exposure to 
infective material is more likely to be successful than 
intermittent and occasional exposure. (2) Intimate con- 
tact, as between husband and wife, and still more — because 
of the possibilities associated with long latency — between 
parent and child, is more likely to cause infection than the 
less intimate contact which characterises the usual conditions 
of work. 

It has to be remembered, however, that the dust inhaled in 
many occupations may not only serve as a vehicle for the 
tubercle bacillus ; but if, as frequently happens, it is angular 
or rough, may serve as an inoculating needle for the bacillus ; 
and by this means it is conceivable and in fact likely that 
smaller doses of infective material than in domestic life may be 
made almost equally efficient. 

Table XXVIII. —Phthisis 

Comparative Mortality Figures of Males aged 25-65, the total Deaths 
of all Males at these Ages being taken as 1000 



Among 


1890-91-92. 


1900-OI-02. 


Percentage 
Decline or 
Increase in 
Ten Years. 


Occupied Males — 

(a) in England and Wales as a whole 

(b) in London ..... 

(c ) in industrial districts . 

(d) in agricultural districts 
Unoccupied Males ..... 


214 
321 
258 
157 
521 


175 
262 
202 
125 

583 


-18 
-18 
-22 
-20 
+ 12 



158 



THE PREVENTION OF TUBERCULOSIS 



The chief available and approximately accurate statistics of 
phthisis in relation to industrial occupations are those supplied 
in the Decennial Supplements to the reports of the Registrar- 
General of Births and Deaths. The results of the last two of 
these reports, which are by Dr. Tatham, are given in Table 
XXVIII. on previous page. The meaning of the words 
comparative mortality figure has already been explained on 

P- 155. 

Unoccupied males represent a large proportion of invalids, 
and we may leave them out of consideration. The excess of 
phthisis in industrial over agricultural districts will be noted, 



Table XXIX.— Phthisis 

Comparative Mortality Figures of Males aged 25-65, the total Deaths 
of all Males at these Ages being take?i as 1000 



Occupation. 


Comparative Mortality Figure. 


Percentage 
Decline or 
Increase in 
Ten Years. 


1890-91-92. 


1900-01 -02. * 


Occupied males .... 

General shopkeeper 

Lead miner ..... 

Tool, scissors, file-maker 

File-maker ..... 

Copper miner .... 

Cutler, scissors-maker . 

Tin miner 

Messenger, porter .... 

General labourer (England and 

Wales) 

; Costermonger, hawker . 

I General labourer (London) 

! General labourer (industrial districts) 

| Inn, hotel servant (agricultural dis- 
tricts) 

Inn, hotel servant (industrial dis- 
tricts) 

Innkeeper, servant, etc. (London) . 
Inn, hotel servant (England and 

Wales) 

j Inn, hotel servant (London) . 


214 

272 
440 
390 
467 

384 
442 
586 

376 

295 
514 
445 
363 

412 

415 
519 

552 
705 


175 

344 
317 
353 
375 
501 
516 
838 

368 

45o 
516 

53i 
567 

410 

426 

443 

533 
669 


-18 

+ 26 

-28 

- 9 
-20 

+ 30 
+ 17 
+ 43 

- 2 

+ 53 
+ 
+ 19 
+ 56 

- 

+ 3 
-15 

- 3 

- 10 



1 The above corrected figures are supplied through Dr. Tatham's kindness, 
before the publication of Part II. of the Decennial Supplement for 1 891-1900. 



INDUSTRIAL INFECTION 159 

and the still greater excess in London. It is also noteworthy 
that the decline of phthisis among occupied males is about equal 
in industrial and agricultural districts. 

In Table XXIX. is shown the relative position of the 
chief occupations in association with which fatal phthisis is 
particularly prevalent. 

Among all occupied males there has been in ten years a 
decline of 18 per cent, in phthisis, as compared with a decline 
of 22 per cent, in the general population. The great excess 
of phthisis among males in towns and the special figures in the 
preceding table indicate that a most fertile line of work is 
open in the prevention of industrial phthisis. The class of 
occupations in which the excess of phthisis is greatest, and 
in which this excess is increasing, throw much light on the 
lines of preventive work which are indicated. The occupations 
in Table XXIX. can be classified under three heads: (1) Those 
in which the workers are exposed to irritating and injurious 
dust, as scissors-makers, file-makers, tin miners; (2) those 
who are particularly prone to alcoholic excess, and are 
particularly exposed to infection from indiscriminate expec- 
toration, as innkeepers and inn servants ; and (3) those whose 
work is casual in character, and who likewise are addicted to 
frequenting public - houses, as general labourers, messengers, 
costermongers. The occupation of a "general labourer" in- 
cludes many loafers, as well as many who have fallen from 
skilled occupations owing to illness ; and it is difficult to dis- 
tinguish between the public-house and the industrial factors, 
or to state in the case of how many the ill-health prevented the 
patient securing a more stable occupation. It will be noted that 
general labourers showed a marked increase, while hawkers and 
messengers showed little or no decrease, of phthisis. Innkeepers 
and inn servants have in some districts made their previous bad 
record worse. Lead miners and file-makers show considerable 
improvement, while tin miners, copper miners, and cutlers have 
become worse. 

The obvious indications for prevention are the diminution or 
removal of dust, the substitution of wet cleansing for sweeping, 
the use of fans to divert dust from the workshop. The operation 
of the Workshops and Factories Acts is gradually improving the 
condition of workshops and factories ; but evidence of improve- 



i6o THE PREVENTION OF TUBERCULOSIS 

ment has not yet shown itself to a marked extent in the death- 
returns for phthisis among miners and among general shopkeepers, 
as is indicated in Table XXIX. Another decade will doubtless 
see great advance in the directions indicated above, and will 
bring nearer the realisation of the benefit from preventive- work 
already being done. 



CHAPTER XXII 
SUSCEPTIBILITY TO INFECTION 

A SPECIAL susceptibility to infection, hereditary or acquired, 
is generally regarded as appertaining to those who become 

tuberculous, and as being indeed necessary for the develop- 
ment of tuberculosis when infection is received. In those showing 
this special susceptibility vital resistance to invasion by disease 
is supposed to be deficient, or the patient is said to be abnormally 
vulnerable to disease. The resulting amount of disease which 
will follow infection by the tubercle bacillus will vary on the one 
hand according to the number and virulence of the particular 
bacilli introduced into the system, and on the other hand 
according to the resistance of the patient to invasion. 

It is extremely difficult to resolve resistance into its con- 
stituent factors, and in fact it cannot be done with exactitude. 
In part it consists of innate, and in part of acquired powers, and 
the resistance may prove its power after as well as at the time of 
the invasion by bacilli. The difficulties of estimating resistance 
are particularly great in a disease which is so prevalent as 
tuberculosis. Nearly one-ninth of the deaths in the total 
population result from invasion by the tubercle bacillus, and, 
judging by hospital experience, as many as half of the adults 
of the working classes dying of other diseases show indication 
post-mortem of some degree of past tuberculous invasion, either 
in the lungs or elsewhere. The latter evidence may be re- 
garded as indicating either almost universal proclivity to a certain 
extent, or some measure of immunity on the part of a very high 
proportion of the total population. The former view appears to 
me to be nearer the truth, as all degrees of lesions are found in 
the above cases, and a very high proportion of the total number 
of those who have suffered severely from tuberculosis recover 
completely and die from other diseases. In view of the 
two aspects of the case it is not surprising that the clinician 

ii 



162 THE PREVENTION OF TUBERCULOSIS 

G. See (quoted by Cornet, p. 328) should say that " la predisposi- 
tion est un mot pour masquer notre ignorance " ; or that , on the 
other hand, J. Kingston Fowler (1898, p. 305) should say : — 

Although infection must be regarded as the causa sine qua non, it is 
not necessarily of most importance from a practical point of view. If 
of a large number of persons exposed to infection only a few acquire 
a disease, the susceptibility of the individual becomes a factor in causa- 
tion of greater moment than exposure to infection. 

The underlying assumption in the position taken up by those 
holding the view expressed in the above quotation appears to be 
that everybody " exposed" to infection necessarily receives an 
efficient dose of infection. The error of this assumption can be 
seen by ascertaining what happens when a given number of 
persons are exposed to the infection of acute infectious diseases 
like scarlet fever, diphtheria, and enteric fever. The instances 
best lending themselves to such an inquiry are milk outbreaks 
of these diseases, as in these the element of chance appears to 
be largely eliminated, and it is reasonable to believe that the 
infective material is distributed throughout the milk. In such 
outbreaks the families invaded by the disease in question may 
be as low as 6 per cent, of those supplied with the infected milk in 
scarlet fever, n per cent, in typhoid fever, and 7 per cent, in 
enteric fever (Newman and Swithinbank, 1903, p. 268). I have 
known two milk outbreaks of scarlet fever in which the percentage 
of families affected was considerably lower than 6 per cent. 
It has to be noted, furthermore, that the percentage of persons 
affected in the families supplied with milk from the infected 
source would be much less than the above. The fact is that 
in all these diseases a very large proportion of the persons ex- 
posed either escape because they do not receive any infection, 
just as in battle the majority of soldiers are not shot, or else 
receive an inefficient dose of infection, like soldiers who are 
touched by spent bullets. The circumstances which limit infec- 
tion among those " exposed " to tuberculosis have been already 
fully discussed (p. 101). 

It should be noted further that in comparing tuberculosis 
with the three acute infectious diseases just named, we are in 
tuberculosis, with a few imperfect exceptions, restricted to 
mortality statistics, while we have complete records of total cases 
in the other diseases. The fact that old localised and cured 



SUSCEPTIBILITY TO INFECTION 163 

tuberculous lesions are so often found at autopsies does not 
appear to me to indicate that the majority of the population are 
naturally immune to tuberculosis ; any more than it would be 
justifiable to state that the majority of the population are natur- 
ally immune against the three following infectious diseases, 
because in scarlet fever about 95 out of every 100 attacked, in 
enteric fever about 85, and in diphtheria 80 to 90 out of every 
100 attacked, recover. 

When, therefore, we use Allbutt's (1899, p. 1149) phrase of 
" openness to consumption," it must be remembered that the 
presence of a constant and inherent " openness." in certain 
individuals or in certain families is not demonstrated, however 
likely it is. It is useful to assume its existence, as a reason for 
additional precautions in the cases in which the family or personal 
history points to such " openness " ; but in experience it is 
difficult if not impossible to obtain exact evidence of such " open- 
ness," in which the disturbing factor of excessive exposure to or 
excessive dosage of infection can be entirely eliminated. 

In Chapter XXIV. we shall deal with those personal con- 
ditions, often temporary in character, which appear to diminish 
the resistance to infection ; such as the state of nutrition, 
alcoholism, overfatigue, and injuries. Age and sex as bearing 
on the same problem are discussed in Chapter XXIII., while in 
Chapter XXV. the possible influence of heredity in producing 
a congenital susceptibility will be discussed. 



CHAPTER XXIII 

AGE AND SEX 

ALL investigators agree that tuberculosis is rare in infancy, 
when stated in proportion to the infantile population. 
This is true, notwithstanding the national statistics as 
to the number of deaths caused during infancy by tuberculous 
meningitis and tabes mesenterica. Even when stated in pro- 
portion to the total infantile deaths from all causes, the number 
verified by autopsies is small. Thus Hervieux at the Paris 
Foundling Hospital found on careful post-mortem examination 
only ten cases of tuberculosis, or about i per cent, in 996 infants 
who had died in the first year of life. Frebelius in ten years 
had 16,581 autopsies on infants aged one to four months at 
the St. Petersburg Creche, and found tuberculosis in 416, or 
o*4 per cent. Schwer, in 690 infants dying under one year of 
age, found 44 tuberculous, or 6*3 per cent. These were dis- 
tributed as follows : — 

263 infants aged I day to 4 weeks — o tuberculous = o per. cent. 

123 „ „ 5 to 9 weeks— 1 ,, = o"8 „ 

144 ,, ,, 9 weeks to 5 months — 15 ,, =10*4 ,, 

160 j, ,, 6 months to 1 year — 28 ,, =I7'5 ,, 

The number of deaths from tuberculosis rapidly became 
more numerous in the second year of life ; and, according to 
Papassine, Rilliet, and Barthez, towards the age of five, half 
the deaths of children which occur are due to tuberculosis. 
This figure does not correspond with the figures for England 
and Wales in 1901. If reference be made to Tables XIV. and 
XV. it will be seen that the highest recorded death-rates from 
tuberculous meningitis (109) and from tabes mesenterica (125 
per 100,000) are at ages 0-5, while that from phthisis (315 per 
100,000 for males) is at the age -period 45-55. Without 
accepting the complete accuracy of the rates for the two first, 

it is at least evident that as fatal diseases they are chiefly 

164 



AGE AND SEX 



165 



children's diseases, while fatal phthisis is chiefly a disease of 
adults. Tatham has drawn attention to the fact that the 
age of maximum mortality from phthisis has been postponed 
in both sexes as shown below : — 



Table XXX. — Ages of Maximum Mortality from Phthisis 

{The age-periods in heavy type have the maximum rates ', the others 
being approximate) 



Periods. 


Males. 


Females. 


1851-60 .... 
1861-70 .... 
1871-80 .... 
1881-85 .... 
1886-90 .... 
1891-95 .... 


20-25, 25-35, 35-45 
25-35, 35-45 

35-45 

35-45 
35-45, 45-55 
35-45, 45-55 


25-35 
25-35 
25-35 
25-35 
25-35, 35-45 
35-45 



This postponement may be ascribed to a greater saving of 
life at those ages formerly most liable to death from this disease, 
or to a postponement of death in those who are attacked by 
it. Probably both causes are at work. In the following 
diagram, taken from Dr. Robertson's annual report for Birming- 
ham (1905), the age distribution of the death-rate from phthisis 
is shown for both males and females, in Birmingham, Sheffield, 
and England and Wales as a whole. 

The diagram on the next page enables us also to compare the 
death-rate from phthisis in the two sexes, and to see the general 
excess of the male rate. It will also be observed that the difference 
between the adult death-rate of males and females respectively 
is much greater in the two great urban centres than in England 
and Wales as a whole, which coincides with the difference noted 
on p. 221, where it is pointed out that urban life is not in England 
materially less favourable to women than rural life, in respect of 
phthisis. In this diagram the female death-rate from phthisis 
is seen to be higher in England and Wales as a whole during 
a large part of adult life than in Sheffield and Birmingham, 
again illustrating the point emphasised on p. 221 as to the failure 
of urban conditions of life to raise the female phthisis death- 
rate. The contrast with the male death-rates from phthisis in 
adult life is very striking. 

In Table XII. and Fig. 6 the death-rates from phthisis among 



Death Rates from Phthisis in several Age-groups. 



OEATH 

RATE 

PER 

10 000 

PERSONS 

LIVING AT 

EACH AGE. 



ENGLAND AND WALES 
SHEFFIELD - - - 
BIRMINGHAM 



1890-99- THUS — >—• 

1890-99- Do. °— 

1905 - Do. i t 




OEATH 
RATe 
PER 

10 000 

PERSONS 
LIVING AT 
EACH AGE. 



Fig. 13. — Death-rates from Phthisis for Males and Females at different Age- 
periods in England and Wales, Sheffield, and Birmingham (Robertson) 



AGE AND SEX 



167 



males at each age - period in 1861-70 and 1901 respectively 
are compared. 

For 1901, the death-rates for children under five have been 
calculated in Dr. Tatham's reports for each year of life, and 
these have been compared with the official figures for 1871-80 
in" the following table : — 

Table XXXI.— Phthisis 

Death-rates per 100,000 of Population living at each of the First 

Five Years of Life 



Period. 


O-I. 


«-2. 


2-3- 


3-4- 


4-5- 


All Ages 
under 5. 


1871-80 . 

1901 .... 


141 
49 


117 

44 


54 34 
26 18 


30 
15 


77 
3i 



It has not been thought necessary to subdivide these accord- 
ing to sex. 

I In the following table the male and female death-rates from 
phthisis in four successive decennia are given for the first twenty 
years of life : — 



Table XXXII. — England and Wales 
Pulmonary Tuberculosis 



Period. 


Death-rates per 100,000 of Popula- 
tion living at Ages 


Relative Death-rate of 

Females, that of Males 

being stated as 100. 


o-5- 


i i 
5-10. j ic-15. 15-20. 


0-5. 5-10. 


10-15. 


15-20. 




M. 


F. 


M. 


F. 


M. 


F. 1 M. 


F. 










1861-70 . 


99 


9=i 


43 


48 


61 


105 ■ 219 


3ii 


96 


in 


173 


142 


1871-80 . 


78 


75 


34 


38 


48 


85 ; 168 


240 


96 


no 


176 


143 


1881-90 . 


55 


52 


25 


33 


34 


70; 129 


180 


94 


129 


204 


140 


1891-1900 


44 


39 


17 


24 23 


50 100 


129 


87 


137 


215 


130 



Taking the first five years of life together, it will be 
noted that in 1891-1900 the female is 13 per cent, lower 
than the male death-rate, a difference which has not hitherto 
been explained. The sex difference at ages 0-5 in the three 



i68 



THE PREVENTION OF TUBERCULOSIS 



previous decades varied from 6 to 4 per cent. At ages 5-10 
there has been throughout the forty years a greater female 
than male rate. At first the excess of the male rate was 10 to 
11 per cent., it then increased to 29 per cent., and in the last 
decade became 37 per cent. In the next age-period 10-15, 
the excess of the female rate is even more striking : in 1861-80 
it was 73 to 76 per cent, higher than the male rate, in the last 
twenty years the female has been more than double the male 
rate, and the sex difference has increased in the last decade. 
At ages 15-20 an inverse process on a smaller scale is visible. 
The female rate was 42 to 43 per cent, higher than the male 
in the first twenty years, in the third decade it was 40, and in 
the last decade it was 30 per cent, higher. It is most difficult 
to explain these differences and the changes in the differences, 
assuming that they represent actual facts. Sir Hugh Beevor 
(1899) thinks that there is a true sex difference as regards this 
disease at the ages of rapid growth. The growing lung " is able 
to resist infection; resistance of the growing lung effectively 
accounts also for the very regular difference in the sex incidence 
of phthisis up to the age of 20." He draws attention to the 



Table XXXIIL— Phthisis 
Death-rates per 100,000 













Relative Death-rates 




Males. 


Females. 


in 1891-1900, the 
Death-rate for 1861-70 












being stated as 1 00. 


Ages. 


1861-70. 


1891-1900. 


1861-70. 


1891-1900. 


Males. 


Females. 


0- 


99 


44 


95 


39 


45 


4i 


5- 


43 


17 


48 


24 


40 


5o 


10- 


61 


23 


105 


50 


39 


48 


15- 


220 


100 


312 


129 


46 


41 


20- 


389 


189 


397 


159 


49 


40 


25- . 


411 


237 


440 


192 


58 


44 


35- 


417 


310 


39i 


212 


74 


55 


45- 


388 


3H 


287 


164 


81 


58 


55- 


33i 


262 


208 


124 


79 


60 


65- . . 


204 


158 


125 


81 


78 


66 


75 and upwards 
All Ages 


66 


56 


45 


35 


84 


79 


254 


158 


255 


121 


62 


48 



AGE AND SEX 



169 



earlier and more rapid general development, and particularly 
of the lungs in girls. Thus growth in height in girls is com- 
pleted at the age of 15 years, while boys go on growing two 
or three years later, and he connects this fact with the higher 
female phthisis rate at ages 10-15. However applicable this 
explanation may be for the ages 10-15, it can scarcely be appli- 
cable to the ages 5-10, in which the female rate is to a less extent 
excessive. It is likely that the excess at all ages 5-20 among 
girls is partially explicable on the ground that they live a much 
less outdoor life than boys, and are much more constantly 
exposed to domestic infection. 

In the table on the preceding page the death-rates at 
different ages from phthisis are given separately for the two sexes 
at intervals of thirty years. 

It will be seen that at ages 0-5 the decline in the male death- 
rate from phthisis has been 4 per cent, less than that in the 
female rate ; that at ages 5-15, the decline has been 10 per cent, 
greater in the male than in the female rate. At ages 15-20, the 
difference is only 5 per cent. At all subsequent ages the decline 
has been less among men than among women, this being most 
markedly so at ages 45-65. 

The relation between the death-rates from phthisis in the 
two sexes can be further studied in the following table : — 



Table XXXIV.— Phthisis 

Relation of Female to Male Mortality at each Age and in each Period^ 
that of Males for the same Age and Period being stated as 100 



Period. 


0- 


5- 


10- 


iS- 


20- 


25- 


35- 


45- 


55- 


65- 


75 and 
upwards. 


1861-70 
1891-1900 . 


96 
87 


iii 
i37 


i73 

215 


142 
130 


103 

84 


107 

81 


94 
69 


74 
52 


63 

47 


61 
5i 


68 
63 



The relations shown in this table are set out graphically in 
Fig. 14. 

It will be observed (a) that at the two extremes of age there 
is little change in the relation which the male and female death- 
rates bore to each other in 1861-70 and in 1891-1900 ; (b) that 
in adult life women have gained considerably more than men ; 
and (c) that they have lost as compared with boys at ages 5-15. 















































75 
UPWARDS 






























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Fig. 14.- 



-Female Death-rate from Phthisis at each Age-period, that of Males 
at the same Age-period being stated as 100 

1861-70 . . •— •— • • 

1891-1900 . . •---•---#---# 



AGE AND SEX 



171 



It is necessary to bear in mind that all the preceding figures 
deal with deaths. The date at which infection was received 
may have been less than a year, or may have been very many 
years before death (Chap. X.). Thus the excessive death-rate of 
girls aged 10-15 may be in part due to the strain of the changes 
undergone at puberty, — a strain greater than in boys, — calling 
latent infection into activity, as well as to recent infection caused 
by their indoor habits, as suggested on p. 169. 

Changes in the Sex Incidence of Phthisis. — This subject 
deserves further study from the historical standpoint. In 
England and Wales the female death-rate from phthisis has been 
lower than the male rate from 1866 onwards, in Massachusetts 
it was as high as or higher than the male rate until 1896. In 
Prussia since 1876, when statistics first became available, the 
male has always been higher than the female rate. In Scotland 
the female was higher than the male rate until 1885, when the rates 
for the two sexes were nearly equal. In more recent years the 
position of the two has changed without consistency, but from 
1898 onwards the female has always been lower than the male 



Table XXXV 

The Relative Male and Female Death-rates from Phthisis^ 
that of Males being stated as 100 1 









England 
and Wales. 


Massa- 
chusetts. 


Providence, 
U.S.A. 


Prussia. 




Male. 


Female. 


Male. 


Female. 


Male. 


Female. 


Male. 


Female. 


1851-55 
1856-60 
1861-65 
1866-70 
1871-75 

1876-80 
1881-85 
1886-90 
1891-95 

1 896- 1 900 






100 

100 
100 
100 
100 
100 
100 
100 
100 
100 


107 

108 

104 

103 

93 

9i 

84 

84 

80 

74 


100 
100 
100 
100 
100 
100 
100 
100 
100 
100 


137 
123 
109 
112 

113 
119 
114 
106 

104 
95 


100 
100 
100 
100 
100 
100 
100 
100 
100 


131 
91? 

IOI 

109 
112 

IOI 

93 
92 
86 


10 
10 
10 
10 
10 




D 


3 



80 in 1876 

84 ,, 1881 
83 „ 1886 

85 „ 1891 
83 ,, 1896 

and 1 90 1 



1 The correction of the death-rates for males and females respectively for 
differences due to age distribution of population in the two sexes was not practi- 
cable. It is unlikely that such correction would seriously alter the comparisons 
in the above table. 



172 



THE PREVENTION OF TUBERCULOSIS 



rate. In Ireland from 1864 to 1873 the male and female rates 
were close together ; afterwards the female became increasingly 
higher than the male rate. In the last few years the two rates 
have approached again ; in 1903 the female death-rate was 2 '2 
as against 2*1 per 1000 for males. In the table on preceding page 
the relative sex incidence of the death-rate in Massachusetts 
and England is given for a series of years. 

Mortality in the Two Sexes in Urban and Rural Life. — 
The influence of urban or rural conditions of life on the relation 
of the male to the female phthisis rate is also of interest. For 
Prussia this is seen in the following table : — 



Table XXXVL— Prussia 

The Relative Male and Female Death-rates from Phthisis ', 
that of Males being stated as 100 





Towns. 


Rural Communes. 


Year. 








Male. 


Female. 


Male. 


Female. 


1876 


100 


74 


100 


88 


1881 


100 


76 


100 


89 


1886 


100 


73 


100 


90 


1891 


100 


74 


100 


95 


1896 


100 


72 


100 


93 


1901 


100 


73 


100 


95 



This table fits in with the facts set forth on pp. 220 to 224, 
which showed that the female death-rates from phthisis are 
nearly equal in rural and urban counties of England, while the 
male death-rates are much higher in urban than in rural counties. 
The comparison in the case of England and Wales can be pursued 
into the different age-periods. The result is shown in Figs. 15 
to 18, the data from which are taken from p. xcvi of Dr. Tatham's 
Letter to the Registrar-General (1905). 

(a) Comparison of urban and rural life for males. In Fig. 15 
it will be observed that throughout the early part of life up to the 
age-period 25-35 the male phthisis rate is higher in rural than 
in urban counties. After that age the rural rate ceases to rise 
and falls slowly, while the urban rate rises, being highest at the 
age-period 45-55. The evil effects of urban conditions of life 



AGE AND SEX 



173 





















MALES 

Death Rate, per Mill 


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UPWARDS 



Fig. 15. — 1905. Death-rate from Phthisis per million of Males living at each 
Age-period, in Urban and Rural Counties 



174 



THE PREVENTION OF TUBERCULOSIS 



and work in increasing the male phthisis rate at the higher ages 
are well shown. 

(b) Comparison of urban and rural life for females. In Fig. 16 

FEMALES 

DeaJJi Rate, per Million 



























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UPWARDS 



Fig. i 6. — 1905. Death-rate from Phthisis per million of Females living at 
each Age-period, in Urban and Rural Counties 



the contrast to the male experience is very evident. At the 
ages 5-15 urban and rural experiences are almost identical. 
From 15-20 to 25-35 the rural phthisis rate among females is 
much higher than the urban. From that age-period onwards 
the rural is lower than the urban rate. 

(c) Comparison of males and females in urban districts. The 
failure of the female rate to rise to the same extent as the male 
rate at ages after 20 is well seen in Fig. 17. 

In Fig. 18 is given a similar comparison for rural 
counties. 



AGE AND SEX 



175 





















i 


URBAN 

Death Rate per Million 






























































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UPWARDS 



Fig. 17. — 1905. Death-rate from Phthisis per million of Males and Females 
living at each Age-period in Urban Counties 



176 



THE PREVENTION OF TUBERCULOSIS 























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UNDER 

5 
YEARS 


5- 

-10 


10- 

-15 


15- 
-20 


20- 
25 


25' 35 


35-45 


45-55 


55-65 


65 

UPWARDS 



Fig. 18. — 1905. Death-rate from Phthisis per million of Males and Females 
living at each Age-period in Rural Counties 



CHAPTER XXIV 

PERSONAL CONDITIONS LOWERING RESISTANCE TO 

INFECTION 

IT has already been stated, that not only differences in age 
and sex, but also more or less temporary individual con- 
ditions, affect the proclivity to tuberculosis. Of these 
fatigue, injuries, and attacks of diseases other than tuberculosis 
are important ; and the state of nutrition, with particular refer- 
ence to alcoholism, also needs discussion. 

Fatigue. — Over-exertion is well known to predispose to 
infection. The common method of origin of an ordinary catarrh 
is an illustration of this, and there are numerous instances in 
experimental bacteriology. Thus Charrin and Roger showed 
that normal rats, which are but slightly susceptible to anthrax, 
become highly susceptible when fatigued by working at a tread- 
mill. 

Clinically a history of bodily or mental over-exertion, of pro- 
tracted emotional excitement or anxiety, as after a competitive 
examination or the prolonged nursing of a sick relative, is a 
frequent prelude of acute phthisis. On this point Dr. Burton- 
Fanning (p. 24), says : — 

To my mind there are few causes more powerful to determine the 
outbreak of pulmonary tuberculosis than physical over-exertion. In at 
least 10 per cent, of my patients the disease seemed directly attributable 
to their having overdone themselves. A feat of endurance is apt to 
overstrain the constitution, and break down the defences of an apparently 
healthy man against the tubercle bacillus. It had already gained, we 
assume, a footing in his system, and only waited an opportunity to mani- 
fest its activity. I have been struck by the frequency with which con- 
sumption attacks men who have distinguished themselves in various 
athletic pursuits. This remark particularly applies to such sports as tax 
the powers of endurance, such as long-distance bicycle riding or running, 
rowing, or, in fact, any exhausting exercise. It is important to recognise 
that, although such exercise be taken in the open air, it is conducive to 
the development of consumption if it entails exhaustion or fatigue. 
12 



178 THE PREVENTION OF TUBERCULOSIS 

Injury. — The apparent influence of local injury in deter- 
mining the site of tuberculous disease of bones and joints is well 
recognised. Injury to the chest wall has sometimes appeared 
to light up active phthisis. There is no reason to doubt that 
injury may, by lowering the local phagocytal influence, enable 
latent tubercle bacilli to assume active life. 

Diseases other than Tuberculosis. — Tuberculosis is 
commonly associated with certain diseases, especially with 
chronic insanity. The death-rate from phthisis is very ex- 
cessive in the insane in asylums. From the pathological evidence 
collected by Dr. Mott it is clear that a very large part of this 
tuberculosis was present in a latent condition when the patients 
were admitted to the asylums ; and that the tuberculosis must 
be regarded as acting in insanity as it does in diabetes by 
hastening death, the devitalised condition of these patients 
enabling the tubercle bacillus to proceed with its ravages un- 
molested. The annual death-rate from tuberculosis in borough 
and county asylums is about 16 per iooo occupants, which is 
more than seven times as high as that in the total adult population 
of England and Wales. 

Certain acute infectious diseases, especially influenza, whoop- 
ing-cough, measles, and to a less extent scarlet fever and enteric 
fever, undoubtedly favour the occurrence of tuberculosis. Prob- 
ably they act in two ways : (a) in all these diseases irritation of 
mucous membranes and denudation of their epithelium is 
caused, and the way is opened for the entrance of the tubercle 
bacillus ; (b) probably these diseases act more commonly by 

Table XXXVII. — England and Wales 
Annual Death-rate per million of Population 





1888. 


1889. 


1890. 


1891. ; 1892. 

i 


1893. 


Influenza 
Phthisis 


3 
1568 


2 
1573 


157 
1682 


574 ! 533 
1599 1468 

1 


325 
1466 



Note. — In 1890, although probably doctors had not yet begun to record 
deaths as due to influenza to the full extent which the facts justified, it 
was already widely prevalent, and the sudden excess of deaths ascribed 
to phthisis occurred in this year. Probably many phthisical patients 
with an unstable tenure of life died as the result of intercurrent influenza. 



LOWERING RESISTANCE TO INFECTION 179 

causing swelling and infiltration of lymphatic glands, often 
already containing tuberculous foci, the migration from which of 
tubercle bacilli to internal organs is thus greatly favoured. The 
influence of influenza in increasing the death-rate from phthisis 
is shown in our national death returns. As a rule, the annual 
death-rate from phthisis shows no epidemic peaks, but declines 
smoothly by a small percentage year by year. This course was 
interrupted in the years 1890-91 in which influenza after a long 
interval again became epidemic, as shown in the table on the 
preceding page. 

Common catarrhs are credited with an important influence in 
causing phthisis, especially when neglected. Possibly they act like 
acute specific fevers by denuding epithelium and by causing 
glandular enlargements, thus setting free encysted tubercle 
bacilli. More often the real connection is one of identity. What 
is regarded asa" severe cold," a slight " attack of influenza," 
or a "touch of bronchitis," is in fact an attack of pulmonary 
tuberculosis, from which the patient temporarily recovers, with 
frequent relapses. Whether there be any connection between 
neglected catarrhs and phthisis or not, it is certain, as pointed 
out by Clifford Allbutt, that the belief in it has had a lamentable 
effect on the treatment of the latter disease. Indoor confinement 
and stuffy rooms have been prescribed, when abundant fresh air 
was indicated. The common indication for treatment both in 
catarrh and in febrile phthisis is absolute rest with as close an 
approximation to open-air conditions as possible. 

The association between bronchitis and phthisis has been 
much discussed. Many cases of senile phthisis are overlooked 
on account of the presence of emphysema. It is likely that 
many cases starting as true bronchitis have phthisis engrafted 
on this disease. This is especially so in many occupational 
diseases. 

Malnutrition. — As shown on p. 230, good nutrition is 
considered by some authorities to play a very important part 
in the prevention of tuberculosis, although the evidence given 
on pp. 230 to 243 does not justify the conclusion that on a 
national scale any marked inverse relationship between phthisis 
and nutrition holds good. The same remark applies to ex- 
posure to weather, cold, and hardship, which may be regarded 
as representing so much excessive loss of benefit derivable 



180 THE PREVENTION OF TUBERCULOSIS 

from a given amount of food. Thus Ransome (1890, p. 50) 
says : — 

The Highlanders, who inhabit well-built houses on the mainland of 
Scotland, are subject to the same fate as the other inhabitants, whilst 
the ill-fed, ill-clothed fishermen of St. Kilda and the Hebrides, who are 
of the same race, hardly ever contract the disease. 

In another paragraph on the same page Ransome gives a 
second illustration, which may also be quoted : — 

The terrible mortality from phthisis that prevailed at one time amongst 
the finest soldiers of the British Army was certainly not brought on by 
starvation or misery. It occurred for the most part when they were 
not on active service, but in a time of peace, when they were well fed and 
well cared for so far as their bodily comfort was concerned — far better, 
in fact, than the half-starved workpeople and labourers, who only died of 
the disease at one-third the rate they did. 

The experience of Ireland, given more fully on pp. 217 and 
233, tells the same story. Between 1870 and 1903 the wages of its 
agricultural labourers have increased 42 per cent., while the cost 
of food has greatly diminished and its death-rate from phthisis 
has increased. 

Dr. Stafford of the Irish Local Government Board has 
recently given the death-rates from phthisis in the years 
1900-02 in the two Dublin Poor Law Unions and in the county 
of Mayo respectively. In Dublin the phthisis death-rate is 3*4 
and in Mayo 1*4 per 1000. He adds that 

for scantiness of the means of subsistence the general condition of the 
inhabitants of County Mayo could scarcely be surpassed. It is clear, 
therefore, that poverty alone may be present in an acute form and on a 
large scale without producing an excessive mortality from tuberculosis, 
and that some other factor or factors as well as poverty exercise a determin- 
ing influence in producing the excessive death-rate from tuberculosis. 

It is important to bear in mind these illustrations following 
from the fact that circumstances other than differences of 
nutrition affect the proclivity to tuberculosis. They show that 
no general measures of improvement in well-being by themselves 
suffice to control the disease. But beyond question malnutrition 
favours tuberculosis, and while the evidence in Part II. amply 
shows that other factors are more important, no system of 
measures for controlling tuberculosis can be regarded as final 
which omits to do what is practicable for preventing malnutrition. 



LOWERING RESISTANCE TO INFECTION 181 

Alcohol. — That alcoholic indulgence favours the occurrence 
of phthisis is shown by abundant evidence, and is well recognised. 
Thus the late Professor Brouardel (1901) of Paris said : — 

Alcoholism is in fact the most powerful factor in the propagation of 
tuberculosis. The most vigorous man, who becomes alcoholic, is without 
resistance before it. 

Although some have obtained opposite results, there are 
many experiments on record tending to show that infections in 
general are more rapid and more grave in alcoholised animals. 
Drs. Achard and Gaillard found in experimenting on rabbits 
that giving alcohol hastened the progress of experimental tuber- 
culosis. For the human being Landouzy has expressed the 
influence of alcoholism as follows : " l'alcoolisme fait le lit de 
la tuberculosa " 

Alcohol and phthisis are related as indicated above, through 
the diminished resistance to the disease caused by alcohol, and 
with that we are chiefly concerned in this chapter. Alcoholic 
indulgence, and still more the occupation of selling alcoholic 
drinks, commonly expose persons to more frequent infection ; 
and this is a prominent factor in causing the excessive death- 
rate from phthisis in certain occupations (p. 159). 



CHAPTER XXV 
HEREDITARY DISPOSITION TO PHTHISIS 

SO far we have been chiefly concerned with factors of causa- 
tion which are all more or less ascertained and defined. 
The influence of heredity differs from these in being still 
more or less sub judice. 

It is considered as acting in two ways : by direct trans- 
mission before birth from parent to infant of the germs of disease ; 
or by the transmission from parent to offspring of a special 
weakness or openness rendering certain persons more liable to 
infection than others. 

The direct Transmission of Tuberculosis from parent 
to child may occur before birth, either germinally — a very rare 
phenomenon — or during intra-uterine life, a more common, but 
still rare, event. 

The passage of the tubercle bacillus through the placental 
tissues to the fcetus has been proved by a number of pathologists. 
Thus Johne found tubercles in the lungs and bronchial glands of 
the eight months' fcetus of a tuberculous cow. MacFadyean found 
cheesy foci in the liver and portal glands of a five days' old calf. 
Similar cases have been described in the human foetus. Frankel 
(1906) thinks that the danger of hematogenous infection through 
the placenta is commonly understated. He quotes Schmorl, 
who found tuberculous nodules in 9 out of 20 or 45 per cent, of 
the placentas of tuberculous women examined by him ; and 
these were found not only in cases of miliary tuberculosis or 
advanced phthisis, but also in a case of incipient phthisis. It 
is possible, furthermore, that the instances in which obvious 
tuberculous lesions are found in the new-born child do not cover 
the entire ground. Other infants may have latent tuberculosis, 
which develops into obvious disease later in life. 

This view is commonly associated with the name of Baum- 
garten, though it was held before his day. He believes that 



HEREDITARY DISPOSITION TO PHTHISIS 183 

either germinal or intra-uterine transmission of infection is the 
most common cause of tuberculosis, and that long latency of the 
infection is the rule rather than the exception. He goes further, 
believing even that a person may have been infected by trans- 
mission through two generations from a tuberculous grandparent. 

The views of Baumgarten, apart from the last-named point, 
are supported by the fact that microscopic examination of 
the liver and inoculation experiments with foetal tissues show- 
ing no naked-eye evidence of disease have occasionally shown 
the presence of tubercle bacilli. Baumgarten considers long 
dormancy of tubercle bacilli in lymphatic glands, the medulla 
of bone, etc., as common, the young tissues of growing animals 
having special resisting power against the bacilli. His view 
involves the unlikely supposition that a very large part of the 
human race carry within them tubercle bacilli at birth. At the 
same time the analogous case of congenital syphilis, with long 
latency of an infection acquired before birth, indicates that 
congenital tuberculosis is within the range of possibility. It is 
possible, as J. K. Fowler has suggested, that evidence will accumu- 
late in favour of the view that sometimes tuberculosis of the 
glands, joints, and bones in children may have been transmitted 
from the parent and remained dormant for several years. To 
prove such cases it would be necessary to show that the mother 
was tuberculous, and that there had been no exposure to infection 
after birth. In the absence of evidence on the latter point, 
either the ordinary view of infection after birth, or the view that 
infection was acquired before birth, would be tenable. 

The fact that visible tuberculosis is more commonly found 

Table XXXVIII 





till Births 

and 
Day Old. 


O c/5 


2 c 



2 c 


2 c 


o\2 

-g 




£ 


PO in 

O £3 


O aj 


"-> 1/2 


O 

H 




tn *■* 
























Number of autopsies . 


184 


250 


S2 


33 


76 


88 


6S 


311 


l89 


160 


1.34 


1^42 


Number with tuber- 


























culous changes 
Per cent, of total . 








2 


8 


15 


18 


83 


56 


51 


30 


263 








61 


10-5 


17-0 


277 


267 


29 6 


31 '9 


22"5 


17-0 



184 THE PREVENTION OF TUBERCULOSIS 

with each additional month after birth, may be explained either 
on the supposition that early-life tuberculosis is in the main 
acquired after birth ; or by assuming that ante-natal tuber- 
culosis remains long latent so far as symptoms are concerned. 
The following illustrations on this point will suffice. Cornet 
(1904, p. 307) gives the figures on the preceding page relating to 
a number of autopsies made on children under 5 years old dying 
in children's hospitals in Berlin. 

These figures clearly show that whether infection is received 
before or after birth, visible changes are not usually shown in 
the body until some months later. (The figures in the above 
table must not be regarded as giving any indication of the true 
frequency of fatal tuberculosis in children. To do this it would 
be necessary to compare the deaths from this disease with the 
number of children living at the same ages. The figures do, 
however, show its rarity in the first few months of life.) 

Veterinary results are to a like effect. Thus Cornet (1904, 
p. 308) gives the distribution of tuberculosis among cattle in 
Saxony, where the inspection of meat is compulsory, as follows : — 



Of 120,490 calves up to 6 weeks of age 
,, 665 cattle from 6 weeks to I year 

,, 6,328 „ ,, 1 to 3 years old 
„ 13,307 >, „ 3 to 6 „ „ 
,, 11,101 ,, over 6 years old 



3, or 0*002 per cent. 

i, „ 0-15 
440, „ 69 „ 

,285, „ 97 
,881, „ 16-9 



The most probable interpretation of the preceding facts is 
that post-natal infection is the usual source of tuberculosis, 
though ante-natal infection occasionally occurs, and it may be 
somewhat more frequent than is generally recognised. 

Hereditary Predisposition. — Phthisis is usually regarded 
as a typically hereditary disease, in the causation of which 
family predisposition plays a large part. The extent to which 
heredity is held to operate has diminished as our knowledge of 
the causation of tuberculosis has become more exact. The most 
prevalent view is contained in the following statement by Drs. 
C. J. B. and C. Theodore Williams (1887, p. 58) :— 

Family predisposition has by general consent held a very prominent 
place, but the value of its influence in the causation of phthisis has been 
modified of late years by the fuller recognition of other causes which had 
been to some extent overlooked — such as damp, inflammatory attacks, 
etc. These and other direct sources of phthisis must exercise in our calcu- 
lations a depreciatory influence on the amount we assign to hereditary 



HEREDITARY DISPOSITION TO PHTHISIS 185 

tiansmission, and numerous cases of this disease which have hitherto 
been held to originate in a consumptive ancestry, will now be traced to 
a nearer and more direct cause. Nevertheless, no small number of cases 
owe their origin to hereditary predisposition, though it is not always easy 
to demonstrate their hereditary character. Its exact value as a predis- 
posing agent, its mode of transmission, the varieties of the disease in 
which its influence is most apparent, — all these and other points of interest 
are by no means settled questions, but still open to further inquiry. 

Similarly Dr. S. West (1902, vol. ii. p. 449) states that 
" recent additions to our knowledge of tuberculosis have greatly 
modified the views held as to the influence of inheritance in 
phthisis " ; but after giving statistics he concludes that " family 
predisposition is an essential factor in phthisis, though probably 
not exerting so important an influence as has been hitherto 
believed." 

The evidence on the strength of which it is considered that 
hereditary predisposition forms an important factor in the 
causation of phthisis consists usually in showing that a large 
percentage of the parents and other relatives of the total con- 
sumptives had also suffered from the same disease. West (p. 449) 
says that about 28 per cent, of the total cases taken at random 
yield, on an average of a large number of cases, a history of 
phthisis in the parents, and about 25 per cent, more in collateral 
relatives. Walshe (1871, p. 461) in a careful investigation of 
162 cases found that 26 per cent, of them had one or both parents 
similarly diseased. J. E. Squire (quoted by Fowler, p. 312) 
gives 12,509 cases of phthisis, showing in 24*8 per cent, of these 
cases that one or both parents had been consumptive. When 
grandparents and collaterals were included, the percentage of 
heredity became 62 "3. Williams (1887, p. 63) thinks that " an 
average of 12 per cent, for direct hereditary transmission, and of 
48 per cent, for family predisposition, are not unfair estimates 
for the upper classes." Wilson Fox found a history of direct 
inheritance in 33 per cent, of hospital cases. 

Facts like the above, although they are commonly regarded 
as good evidence of hereditary influence, are almost valueless 
unless further tested. This was realised long ago by Walshe 
(p. 461), who observed about his own results : — 

Does this result, that about 26 per cent, of my tuberculous patients 
came of a father or mother, or of both parents, similarly diseased, prove, 



iS6 THE PREVENTION OF TUBERCULOSIS 

even in this limited proportion, the reality of hereditary influence 
in the production of the disease ? I think not. It shows that of a 
given generation (b) about 26 per 100 came under ascertainable con- 
ditions of a tuberculous parent (generation a). But this ratio of 26 per 
100 might be, and probably is, no higher than that of the tuberculised 
portion of the population generally. 

In another paragraph (p. 54) he says : — 

If it be true, as always taught, that one in even- three persons dying 
from all diseases indiscriminately in the Paris hospitals has tubercle in 
the lungs, the existence of an almost universal family taint becomes an 
unavoidable inference. 

Phthisis., like scarlet fever, is a common and an infectious 
disease, and the futility of depending on statistics like those 
already quoted, as evidence of hereditary predisposition, may 
be illustrated from the latter disease. For some years past 
I have ascertained in the course of my official experience the 
family experience of households invaded by notifiable infectious 
diseases ; and I recently abstracted 100 family histories of 
scarlet fever in which the records were sufficiently complete 
to be trustworthy. Out of every 100 patients belonging 
to different families, both parents of seven patients had 
suffered from scarlet fever previously, the fathers only of 
sixteen patients and the mothers only of nine patients had 
suffered from scarlet fever, while in 6S per cent, neither parent 
had suffered from this disease. The resemblance to the 
percentages for tuberculous families is striking, and both 
sets of figures alike fail to prove any true hereditary predis- 
position. 

Hereditary Predisposition or Infection. — It is easy 
to prove heredity in the case of a disease like haemophilia, 
where (a) the disease is rare and presumably not infectious, 
and {b) either all or almost all the cases occur among those 
whose ancestors had the same disease. But in phthisis we have 
to deal with a disease which in the first place is infectious, and 
would therefore give no such clear evidence of heredity, even 
if heredity were potent ; and which, in the second place, is very 
common, causing in the general community about one out of 
every twelve male and one out of every seventeen female 
deaths from all causes. Since it is infectious, one cannot 



HEREDITARY DISPOSITION TO PHTHISIS 187 

expect all the cases to be limited to families with hereditary 
taint, however strong this influence may be, and in actual 
fact it is not so limited. Finally, even if it be shown that the 
number of adult deaths from phthisis amongst those with a 
tuberculous family history is in that class much greater than 
the number among a corresponding number of the general 
population similarly situated as to age and sex, it does not 
necessarily follow that this is due to hereditary predisposition. 
It may result from greater exposure to infection. There cannot 
be said to exist satisfactory data enabling this doubt to be 
cleared up. The nearest approach to such data is embodied 
in a " first study " of the statistics of phthisis by Professor 
Pearson, in which the family history of a hypothetical random 
sample of the general community is compared with that of 
consumptives. Even these, however, fail to distinguish between 
family infection and the inheritance of family predisposition. 
An examination of the mathematical method used by Professor 
Pearson would be outside the scope of the present discussion ; 
but it is important to note as a matter involving no criticism 
of method, that his results depend in part upon hypotheses 
which may not be accepted generally as justified, and upon 
ascertained data which may be regarded as too few to warrant 
conclusive inferences. Indeed he himself states : " This investi- 
gation does not profess to be more than preliminary, and its 
results need confirmation when much more numerous data are 
available." He proceeds, however, to state that : " I feel fairly 
confident that for the artisan class the inheritance factor is far 
more important than the infection factor." This statement 
goes beyond Professor Pearson's data, and his assumption that 
in towns the artisan classes can scarcely escape infection, 
except by the absence of the tuberculous diathesis is unproven. 
By infection he doubtless means efficient infection, and no point 
is clearer in the pathology of tuberculosis than that efficient 
infection depends largely on the dosage of infective material. 
The considerations in Chapter XIII. indicate that infection is 
much more limited and localised than is usually supposed. 
It is to be hoped that Professor Pearson's most interesting 
researches may be continued, and that he may receive in the 
future more ample and more complete data from physicians 
than he has hitherto had placed at his disposal. It would 



188 THE PREVENTION OF TUBERCULOSIS 

be a great advantage if, in such a research on a larger scale, 
consumptive families could be classified into groups according 
to the length of interval between the termination of one case 
and the earlier symptoms of successive cases in the same 
family. 

The question asked by Burton-Fanning (1904, p. 22) cannot be 
regarded as a serious contribution towards the solution of the 
problem, without further detailed evidence than is given. He 
asks : — 

If it is entirely a matter of infection and not of heredity, why are the 
members of the family picked out, and other occupants of the house, such 
as the servants, avoided ? 

In the context this writer gives no evidence to show that 
the servants actually escape. Instances are on record in which 
they are known to have fallen victims after prolonged un- 
skilled attendance on consumptives, though the frequent 
migrations of servants render it difficult to obtain such evidence. 
Before importance can be attached to this question, there must 
be evidence on a considerable scale that with fairly equal degrees 
of exposure to infection (both as to duration and intimacy) 
servants escape when relatives suffer. The remarks in Chapter X. 
on long latency have also to be borne in mind in interpreting 
results. 

On the whole, we shall probably not err greatly if we agree 
with Koch's statement (1901, p. 26) that 

great importance used to be attached to the hereditary transmission of 
tuberculosis. Now, however, it has been demonstrated by thorough 
investigation that, though hereditary tuberculosis is not absolutely 
non-existent, it is nevertheless extremely rare, and we are at liberty, in 
considering our practical measures, to leave this form of origination 
entirely out of account. 

The Practical Aspects of Heredity in Tuberculosis. 
— The statement last quoted from Koch must command par- 
ticular approval, when considered in relation to administrative 
measures. From the standpoint of practical public health 
administration, if it were ultimately to be established that 
heredity exercises a greater effect on the transmission of tuber- 
culosis than has hitherto been attributed to it, the measures of 



HEREDITARY DISPOSITION TO PHTHISIS 189 

precaution indicated by this result might be increased in number, 
but none of those of which the adoption is recommended on 
other grounds would become more safely negligible than they 
are now considered to be. The inheritance of a disposition 
to tuberculosis if demonstrated as a general phenomenon would 
show the presence in the community of a larger number of 
susceptible persons than could be inferred from other con- 
siderations. The existence of this larger number of susceptible 
people would call not for the neglect but for the more careful 
enforcement of the precautions by means of which susceptibility 
is prevented from developing into actual infection. The logical 
alternative is to kill off the susceptible stock or, as has been sug- 
gested, to allow them to infect their susceptible brethren and 
together with them perish of their disease. Such proposals 
have only to be stated in their crude terms in order to be 
apprehended and reprehended as an unsocial negation of 
civilisation. 

Marriage of and between Consumptives. — As the matter 
is not separately dealt with in Part III. of this book, it is con- 
venient to add here a note as to the practical bearing of the 
preceding facts and considerations on the marriage of, and 
particularly on the marriage between, consumptives. Assuming 
that advice based on physiological and medical considerations 
will be allowed to carry weight in a matter in which the affec- 
tions alone as a rule are allowed control, it is evident that in 
many instances the marriage of those of consumptive stock is to 
be deprecated, especially when both parties come of such stock. 
On the other hand, when it is remembered that in at least 30 per 
cent, of the adult population there is a history of consumption 
in the antecedents, a sweeping condemnation of such marriages 
can be justified only if it is shown that this percentage is made 
up by a much higher percentage in a relatively small portion 
of the total population. The measure of the actual danger 
in any given instance would be made on the strength of a number 
of facts : — 

(1) At what age did phthisis show itself in the preceding 
generation ? Has the man or woman now concerned passed 
that age ? 

(2) What is the interval since the man or woman now con- 
cerned was last exposed to infection from the consumptive 



i 9 o THE PREVENTION OF TUBERCULOSIS 

relative ; and prior to that what was the duration and extent 
of exposure ? 

(3) Are the circumstances of the person now being advised 
such as are likely to call into activity any latent infec- 
tion ? 



CHAPTER XXVI 

CONDITIONS OF ENVIRONMENT LOWERING RESISTANCE 
TO INFECTION; SOCIAL MISERY; AND INSANITARY 
CIRCUMSTANCES 

TUBERCULOSIS is most prevalent and most fatal under 
conditions of social misery, and when the surroundings 
of the patient are insanitary. It is not surprising, there- 
fore, that it is frequently regarded as due to social misery, and 
that for its prevention many reformers are satisfied with an 
appeal for general social reform, without attempting to analyse 
the constituents of social misery which in particular favour 
tuberculosis. Without attempting any complete analysis of 
social misery and of the insanitary circumstances so closely 
associated with it, it may be said that in it are united in a vicious 
circle, ignorance, privation, and suffering, and that efforts against 
any of these will undoubtedly help to reduce the amount of 
tuberculosis. These factors are in themselves complex. Thus 
privation involves the operation of several influences, to each of 
which it is difficult to apportion its true weight. Underfeeding 
and defective nutrition (pp. 179 and 230) undoubtedly play a 
part in producing the excess of tuberculosis found in the poor, 
though only a relatively small part. Neglect of the ordinary 
rules and precautions of a hygienic life, as to cleanliness, wearing 
of suitable apparel, precautions after exposure to rain and 
weather, and so on, doubtless also favour tuberculosis, though 
no preponderant weight in the balance can be ascribed to them. 
Unfavourable sanitary circumstances of the poor, especially 
housing, play their part ; this is gauged in relation to other 
factors — so far as the data permit — on pp. 224 to 229. Domestic 
overcrowding has already been fully considered on pp. 146 to 149. 
It undoubtedly plays a very large share in the production of 

tuberculosis ; and to this factor more than to any other attention 

i 9 i 



i 9 2 THE PREVENTION OF TUBERCULOSIS 

is required, if the decline in the death-rate from tuberculosis is 
to be made more rapid than at present. 

As no special chapter in Part III. is devoted to ordinary 
sanitary measures in relation to the prevention of tuberculosis, 
it is convenient to consider here the measures practicable against 
it. There are two ways in which overcrowding can be abated : 
one is the slow measure of official inspections, followed by official 
notices in the instances in which overcrowding is detected. 
Those who have official experience know the limitations of this 
method, valuable though it is. Before the limit of legal over- 
crowding (about 350 cubic feet for each person) is reached, there 
may be social overcrowding of a most objectionable character, 
over which official inspection can exercise no control. Even 
when there is suspicion of legal overcrowding, it is very difficult 
to obtain conclusive evidence of its existence, except in lodging- 
houses in which night inspections are possible. Under these 
circumstances official remedies against overcrowding are bound to 
operate slowly, although much improvement has already been 
accomplished. 

The alternative remedy is the removal from the congested 
dwelling of those liable to convey infection. This has been 
done for typhoid and typhus fevers and for small-pox, and has 
led to an immense reduction in their prevalence. In scarlet fever 
and diphtheria similar measures have not been successful to 
an equal extent, because of the failure to track slight cases of 
these diseases, which remain at home or in school spreading 
infection. In phthisis, as shown in Part II., the evidence 
indicates that similar removal of advanced cases from the 
poorest homes has been a predominant cause of the great decline 
in the death-rate from that disease already secured. 

Overcrowding is nearly always associated with other evil 
house conditions — such as defective light and air and absence of 
thorough ventilation — which undoubtedly protract the extra- 
corporeal life and retard the destruction of the tubercle bacilli. 
Do they do more than this ? Some experimental results appear 
to indicate that they may. Thus Trudeau inoculated a number 
of rabbits with equal doses of tubercle bacilli ; half of these were 
allowed to run free in the open air, and the remainder were placed 
in a damp hole to which sunlight had no access. Both sets of 
rabbits were killed at the same time, and it was found that the 



LOWERING RESISTANCE TO INFECTION 193 

first had recovered or only had slight lesions, while the second 
had extensive tuberculosis. 

Ransome's experiments (1895, p. 15) point in the same 
direction. In 1889-90, experimenting with Dreschfield, he showed 
that 

the air of a poor cottage in Ancoats, with poor ventilation and undrained 
basement, in which several cases of phthisis had occurred, was able to 
preserve unchanged the virulence of tuberculous sputum for two or 
three months at least, but that the same sputum exposed freely to air 
and light in a hospital for phthisical patients and also in a well-lighted, 
well-drained, and well-ventilated house entirely lost the power of com- 
municating the disease to guinea-pigs by inoculation. A further research 
carried on in 1894 in conjunction with Professor Delepine proved that 
less than two days' exposure to air and light with only one hour of sunshine 
was sufficient to destroy the virulent power of tuberculous sputum when 
it was exposed in a clean, well-drained, well-lighted house. Evidently 
in the air of the Ancoats cottage there must have been some form of 
organic impurity favourable to the life of the bacillus. 

Whatever be the interpretation put upon these experiments, 
there can be no difference of opinion as to the ill-effects of over- 
crowding, defective light and air, absence of thorough ventilation, 
and still more of domestic uncleanliness in favouring the occur- 
rence and spread of tuberculosis. Probably these factors operate 
chiefly by facilitating the spread of infection ; but it is possible 
that they also tend to devitalise the occupants of such houses 
and render them more ready victims of infection. Whatever 
opinion be held on this point, the indication clearly is to adopt 
the most strenuous efforts to remove these evil conditions, 
wherever found. 



13 



CHAPTER XXVII 
CLIMATE AND SOIL 

CLIMATE. — The anxious inquirer after indications as to the 
climate associated with the lowest death-rates from tuber- 
culosis would not obtain any satisfactory hints from the 
statistics scattered throughout this book, or found elsewhere. It 
may be said in brief that there is scarcely a climate which has not 
been looked upon at one time as predisposing to this disease, and 
at another as curing it. There is no certain evidence that it is 
less prevalent at high than at low altitudes, except in so far as 
the former are usually more isolated and less densely populated 
than the latter. Hirsch (vol. iii. pp. 197-8) has said : — 

The disease occurs ceteris paribus in all geographical zones with 
uniform frequency ; equatorial and subtropical regions are visited with 
consumption not less than countries with a temperate or an arctic 
climate. . . . 

The only statements that can be made in this connection 
with absolute certainty are that 

1. Anything favouring an open-air life diminishes tuberculosis. 

2. Tuberculosis is less prevalent in the less densely populated 
and more isolated communities. 

Soil. 1 — In regard to soil, there is almost equal uncertainty. 
Thorne is quoted by Roberts (1902) as saying that in the pre- 
vention of pulmonary tuberculosis " nothing would do good 
unless people refused to live on a damp subsoil." A damp 
subsoil is stated in all text-books of hygiene to be a most im- 
portant cause of phthisis. 

The proved infectivity of the disease makes it somewhat 
difficult to adjudge what importance should still be attached to 
soil in relation to its causation. It is therefore desirable to 

1 The greater part of the rest of this chapter appeared as an article on " The 

Influence of Soil on the Prevalence of Pulmonary Phthisis "(Practitioner, February 

1901). 

194 



CLIMATE AND SOIL 195 

summarise the evidence and to discuss it in the light of modern 
pathology. 

In order of time, the first observations on the subject were 
made by Dr. H. I. Bowditch (1862). He laid down the " Law of 
Soil Moisture " in the following two propositions : — 

(1) A residence on or near a damp soil, whether that dampness be 
inherent in the soil itself, or caused by percolation from adjacent ponds, 
rivers, meadows, marshes, or springy soils, is one of the primal causes of 
consumption in Massachusetts — probably in New England, and possibly 
in other portions of the globe. 

(2) Consumption can be checked in its career, and possibly — nay, 
probably — prevented in some instances by attention to this law. 

Dr. Gavin Milroy in the Seventh Annual Report of the Registrar- 
General for Scotland (pp. xlvii-xlviii) quoted Dr. Bowditch's 
conclusions drawn " from a very thorough inquiry into one of 
the causes of consumption in Massachusetts." He then pro- 
ceeded to investigate the law. Such an explanation he found 
would agree with the very different proportion of deaths from 
consumption occurring in the eight principal towns of Scotland. 
Taking a five-yearly average (1857-61) the death-rate from 
consumption per 100,000 of population was found to be 206 in 
Leith, 298 in Edinburgh, 310 in Perth, 332 in Aberdeen, 340 in 
Dundee, 383 in Paisley, 399 in Glasgow, and 400 in Greenock. 
Attention was then drawn to the fact that if each town had been 
arranged in the order of comparative dryness of its site, 

they would almost have arranged themselves in the above position — 
Leith and Edinburgh the most free from consumption, and also having 
the driest sites ; Glasgow and Greenock the most ravaged by that disease, 
and beyond all comparison situated on the dampest sites. 

Dr. G. Buchanan's investigation of the same subject was 
embodied in two reports, which were written before he had seen 
the remarks summarised above from the Seventh Report of the 
Registrar-General for Scotland, or Dr. Bowditch's essay on the 
subject. He adds : — 

I should not insist on this point, except for the purpose of giving to 
the conclusions which Dr. Bowditch and myself have obtained, the 
additional weight that they deserve from having been arrived at by a 
second inquirer, wholly ignorant of and therefore unbiassed by the work 
of the first. 

Dr. Buchanan's first report is contained in the Ninth Report 



196 THE PREVENTION OF TUBERCULOSIS 

of the Medical Officer of the Privy Council (1866). This report 
summarises the improvements carried out in 25 towns visited 
in the course of 1865-66, in which the authorities had carried 
out works designed for the improvement of the public health. 
The towns were selected as being places where structural sanitary- 
works had been most thoroughly done, and were not chosen for 
any previously ascertained improvement in their health. The 
general result of the inquiry, so far as phthisis is concerned, was 
that when the sanitary improvements carried out had been 
associated with drying of the subsoil, the phthisis mortality had 
declined, sometimes to one-third or even one-half of its previous 
amount. Great difficulty was experienced in ascertaining the 
degree of drying of the soil, as sewerage works were not executed 
with this direct object in view. It became necessary therefore 
to indicate the degree of drying " in as accurate general terms as 
may be." In the table on the following page I have set forth the 
main results of Dr. Buchanan's research, arranging the towns 
according to the stated influence of sewerage works on the subsoil. 
Thus in the 6 towns in which " much drying " of the subsoil 
followed the carrying out of works of sewerage, the mortality 
from phthisis declined to degrees varying from 49 to 17 per cent. ; 
in 4 of the 5 towns in which " some drying " occurred a decline 
of from 43 to 19 per cent, occurred, but at Ashby-de-la-Zouch an 
increase of 19 per cent, occurred ; in 5 of the 7 towns in which 
" minor degrees of drying " occurred, the reduction was from 
1 to 32 per cent., in Chelmsford the death-rate from phthisis 
remained stationary, and in Carlisle it increased by 10 per cent. ; 
while in 3 of the 5 towns in which " no change in the subsoil " 
occurred, it was reduced from 5 to 8 per cent., and increased 
at Brynmawr to the extent of 6 per cent., and at Alnwick to the 
extent of 20 per cent. Dr. Buchanan notes in his report that at 
Leicester a greater reduction of mortality from phthisis occurred 
during the carrying out of the sewerage works than was subse- 
quently maintained ; and that at Stratford " a large reduction 
of phthisis was for the time observable," although the subse- 
quent decline was only 1 per cent. It is noted also that towns 
which like Salisbury made special arrangements for drying 
their subsoil improved conspicuously, as did also those towns 
with large sewers and those with deep storm culverts. Failure 
to reduce phthisis is also stated to be most observable where, 



CLIMATEIAND SOIL 



197 



as at Penzance and Brynmawr, the soil already contained little 
water, or where the storm water was not properly treated, or 
where the deep drainage consisted of impervious pipes laid down 
in compact channels, as at Penrith and Alnwick. 

Four exceptional cases are pointed out by Dr. Buchanan : 
Chelmsford and Carlisle, which had more lowering of subsoil 



Table XXXIX 





Much Drying of Subsoil. 






Some Drying of Subsoil. 


Previous 






Previous 






Phthisis 


Degree of 




Phthisis 


Degree of 




Death-rate 


Change in 




Death-rate 


Change in 




(all Ages) 


Phthisis 




(all Ages) 


Phthisis. 




per 10,000 


Death-rate. 




per 10,000 


Death-rate. 




Living. 






Living. 

! 


Salisbury 


44i 


-49 per cent. 


Rugby . 


i 

28 J ! - 43 per cent. 


Ely 


32 


-47 „ 


Worthing 


3°£ -36 „ 


Banbury 


26| 


-41 » 


Cheltenham . 


28| 1-26 „ 


Macclesfield . 


SH 


-31 >> 


Bristol . 


33i |-22 „ 


Croydon 


(59*) * 


(-I7) 1 ,, 


Warwick 


40 -19 „ 


Cardiff . 


34! 


-17 „ 


Ashby . 


25i +19 » 




Various Minor 
Degrees of Dry- 
ing of Subsoil. 






No Change in 
Subsoil. 


•S3 &M 


fcJ3 


33 5f C 


1 






C 








s 




J2 " > 








JS ^ > 


« « HI 




fit 13 


FCh 
thisi 
-rate 






Pht 

(all 
Li 


fCh 
thisi 

-rat 




v> <U O 

3 a 


O.C£ 






m v 

2 °- 


^ -5 




•^2 

U "73 


0) e QJ 






1*2 

"5 


&-SQ 






Q 








<u 

Q 


Leicester 


43i 


- 32 p. c. 


Doubtful amount 


Penzance 


30I 


-5 p.c. 








of drying. 


Brynmawr . 


28^ 


+ 6 „ 


Newport 


37 


-32 „ 


Local drying. 


Morpeth 


3oi 


-8 „ 


Dover . 


2 6£ 


-20 „ 


Do. 


Penrith 


39l 


-5 » 


Merthyr 


38* 


-11 „ 


Some recent 
drying. 


Alnwick 


28J 


+ 20 ,, 


Stratford 


26! 


~ 1 ? •> 


Some local 
drying. 








Chelmsford . 


32i 


nil 


Slight drying. 








Carlisle. 


32 


+ 10 ,, 


Drying with 








1 






local defects. 




! 1 



1 Phthisis and lung diseases together. 



198 



THE PREVENTION OF TUBERCULOSIS 



water than some towns which stood well as regards reduction of 
phthisis ; and Worthing and Rugby, which, on the other hand, 
experienced a greater reduction of phthisis than other towns in 
which there occurred a more complete drying of the subsoil. 
The following remark by Dr. Buchanan on this point deserves 
quotation : — 

Perhaps it had better be confessed that there are exceptions to the 
rule of subsidence of phthisis after drying of subsoil ; or the suggestion 
may be allowed that the nature of the change in climatic conditions, 
produced by drying the subsoil of a locality, is not everywhere the same 
(the environs of Chelmsford, for example, still get flooded through the 
action of a mill-dam), and that different degrees of effect may hence be 
produced on consumption. 

Before discussing the facts above summarised, it is desirable 
to summarise Dr. Buchanan's second report made in the follow- 
ing year, in which he proceeded to examine the apparent relation 
between wetness of soil and prevalence of consumption, " with 
direct reference to geological considerations." The necessity 
of taking into account surface peculiarities quite as much as 
the great divisions of the geologist is pointed out. The statistics 
of 58 registration districts in the counties of Surrey, Sussex, and 
Kent, embracing a population of 1,118,372, living on 3812 square 
miles, were taken, the registered phthisis mortality at ages 15-55 
being calculated for each district. On tabulating these it soon 
appeared that " the districts arranged in the order of the pre- 
valence of consumption in them are also to a very large extent 
arranged in the order of the dryness or wetness of their soils." 
Although this was so, the difficulties in classifying districts 
properly were very great, owing to the fact that one section of 
the population of a district might be living on pervious and 

Table XL 



Groups of Districts. 


Percentage Proportion of Population. 


On Pervious Soils. 


On Retentive Soils. 


A. With least phthisis .... 

B. With next least phthisis 

C. Middle as to phthisis . 

D. With still more phthisis 

E. With most phthisis .... 


90-9 
877 
79'5 
79*2 
64*2 


9-1 
12-3 
20 *5 

20'8 

35'8 



CLIMATE AND SOIL 199 

another on impervious strata. In such a district the number 
living on each kind of soil was estimated, and from the results 
thus obtained and the mortality statistics the groups on the 
previous page were derived. 

The preceding classification is, as explained by Dr. Buchanan, 
open to objection, because, for instance, in group D. low plains 
of gravel - covered chalk are reckoned under pervious soils, 
" which might, so far as their water-holding faculty goes, as fitly 
find a place among the retentive formations." 

The alternative plan of classifying districts according to their 
geological conditions brought out more certain conclusions : 
(a) On examining the prevalence of phthisis upon pervious soils 
from which water can drain away, as compared with its pre- 
valence upon retentive soils, it was found that " the descending 
series of the percentage numbers on sands and the ascending 
series of those on clays was wonderfully nearly regular for the 
districts arranged in the order of their consumption ; so much 
is this the case, indeed, that they could not be expected to be 
more regular unless one should go the length of contending that 
phthisis was a disease influenced by no other circumstance than 
the one condition of soil." 

(b) Within the limits of " pervious soils " may be included 
great ranges of wet and dry soils, according to the elevation of 
the ground and the dip of subjacent impervious beds. Thus, 
Chichester, situated on low-lying gravel over London clay, had 
a very unfavourable position for pulmonary tuberculosis, while 
districts on the same gravel, with a sloping clay under it, as at 
Croydon, Epsom, Richmond, occupied a more favourable position. 
In chalk areas again, for similar reasons, there was least phthisis 
on the more elevated portions. On the other hand, low-lying 
districts on gravel and chalk near the sea, e.g. Dover, had a 
favourable phthisis mortality. 

(c) When comparing impervious districts differences were seen. 
London clay had commonly a much less degree of wetness than 
the Weald clay, and there appeared to be a corresponding differ- 
ence in the phthisis mortality. The general results from this in- 
quiry are so important that they deserve complete reproduction: — 

(1) Within the counties of Surrey, Kent, and Sussex, there is, broadly 
speaking, less phthisis among populations living on pervious than among 
populations living on impervious soils. 



200 THE PREVENTION OF TUBERCULOSIS 

(2) Within the same counties, there is less phthisis among populations 
living on high-lying pervious soils than among populations living on low- 
lying pervious soils. 

(3) Within the same counties, there is less phthisis among populations 
living on sloping impervious soils than among populations living on 
flat impervious soils. 

(4) The connection between soil and phthisis has been established in 
this inquiry — 

(a) by the existence of general agreement in phthisis mortality between 
districts that have common geological and topographical features, of a 
nature to affect the water-holding quality of the soil ; 

(6) by the existence of general disagreement between districts that 
are differently circumstanced in regard of such features ; and 

(c) by the discovery of pretty general concomitancy in the fluctua- 
tion of the two conditions, from much phthisis with much wetness of soil 
to little phthisis with little wetness of soil. 

But the connection between wet soil and phthisis came out last 
year in another way, which must here be recalled, 

(d) by the observation that phthisis had been greatly reduced in 
towns where the water of the soil had been artificially removed, and that 
it had not been reduced in other towns where the soil had not been dried. 

(5) The whole of the foregoing conclusions combine into one — which 
may now be affirmed generally, and not only of particular districts — that 

WETNESS OF SOIL IS A CAUSE OF PHTHISIS TO THE POPULATION LIVING 
UPON IT. 

(6) No other circumstance can be detected, after careful consideration 
of the materials accumulated during this year, that coincides on any large 
scale with the greater or less prevalence of phthisis, except the one con- 
dition of soil. 

(7) In this year's inquiry, and in last year's too, single apparent ex- 
ceptions to the general law have been detected. They are probably not 
altogether errors of fact or observation, but are indications of some other 
law in the background that we are not yet able to announce. 



The independent generalisations of Bowditch and Buchanan 
have been generally accepted, and have formed the basis of 
advice which has determined changes of residence for thousands 
of phthisical patients. There have been, however, attempts 
made to minimise or rebut their conclusions. Thus it was 
pointed out by Pearse that in several rainy districts of Devon- 
shire phthisis was but seldom a cause of death ; and that the 
mortality from phthisis was less at Wisbeach, in the fen district, 
than at Axminster on the red sandstone (Lancet, 1876, December, 
p. 833). In Holland, again, there is less phthisis than in 
France, and " the more elevated provinces with diluvial soil 
suffer more than the deep depressions with an alluvial soil, 



CLIMATE AND SOIL 



201 



such as Zeeland, which has the smallest phthisical death-rate " 
(Hirsch, p. 203). 

In this country, the late Dr. C. Kelly, Medical Officer of 
Health of the combined district of West Sussex, a portion of the 
special area investigated by Buchanan, published statistics 
which are not confirmatory of Buchanan's results. In his report 
for 1879 ne showed that the phthisis death-rate had been dis- 
tinctly lowered in that district in recent years, " while very little, 
if any, change has taken place during the same period in the 
drainage of the soil/' Sir R. T. Thorne (1888, p. 51) commenting 
on this statement, said that the large amount of agricultural 
drainage which had then already been effected throughout 
the kingdom would be expected to have produced a result in rural 
districts very similar to that brought about by sanitary drain- 
age in towns. On this point further evidence appears desirable. 
Dr. Kelly gave the following statistics for West Sussex. This 
is a district which covers an area of 335,492 square acres, or 
about 524 square miles, with a population in 1887 of 105,520. 
The different soils found in this district are (1) pervious soils, 
which include the upper and lower greensands, the chalk and 
the lower Tunbridge Wells sands ; (2) the retentive soils, which 
include the Weald clay, the clayey beds of the lower greensand 
and the gault ; and (3) moderately pervious soils, sloping from 
the sea to the South Downs, where the chalk is covered for a 
depth of 15 to 50 feet with loam and brick-earth. 



Table XLI 



Nature of Soil. 


Population. 


Death-rate per 1,000,000 Living at all 
Ages from 


Phthisis. 


Lung 
Diseases. 


All Causes. 


Pervious .... 
Moderately pervious . 
Retentive .... 


33,820 
29,640 
23,530 


I5H 
1467 

1542 


2131 
1892 
2583 


14,852 

14,463 
14,942 



It will be observed that the amount of phthisis is not appre- 
ciably greater among populations living on a retentive than 
among populations living on pervious soils, although other 
respiratory diseases are in excess on the former soil. 



202 THE PREVENTION OF TUBERCULOSIS 

In view of the discrepant results indicated in the preceding 
statistics we may ask whether there is an essential relationship 
between wetness of soil and phthisis mortality among the popu- 
lation living on such a soil, or whether the commonly experienced 
excess of phthisis on wet soils is not due rather to the fact that 
those who are found dwelling on a wet soil are likely to be of 
a lower class of the community, worse housed, and more exposed 
to the infection of phthisis. Buchanan himself agrees that 
there are exceptions to the law, and suggests that " they in- 
dicate the presence of other influences in the subsoil, which 
have hitherto escaped detection." Hirsch suggests, as a more 
probable explanation, that other etiological factors besides 
the influence of soil come into force under the given circum- 
stances, and serve to neutralise the benefits even of the most 
favourable conditions of soil ; and with this suggestion I 
agree. It appears probable that much of the benefit ascribed 
to drying the soil has been due really to other factors of 
improvement which commenced to operate about the same 
time as the former. 

It is difficult to fit in our present knowledge, that the essential 
cause of tuberculosis is the tubercle bacillus, with the wet soil 
theory. It cannot be maintained that such a soil favours the 
growth of the tubercle bacillus, an organism the extra-corporeal 
cultivation of which is beset with difficulties. We can only 
conclude that the wet soil operates merely as a predisposing 
cause. It implies greater loss of heat by evaporation, more 
easy provocation of catarrhs, especially when, as would com- 
monly happen, it is associated with cold and wet houses. Against 
these factors a house even on a wet soil can in a large measure 
be protected. 

The wet soil must be placed, like overcrowding and insuffi- 
cient nutrition, among predisposing causes, infection being the 
chief and essential cause. It must be placed furthermore in 
a lower place than either overcrowding or underfeeding. 

Consumption is essentially a disease of crowded populations, 
of indoor occupations, transmitted by infection, favoured by the 
rebreathing of respired air, and by organic filth of all kinds. 
Crowding, especially crowding of the sick, has greatly declined, 
and was already in the process of declining, while the sewerage 
works referred to in Table XXXIX. were being effected. 



PART II 

THE INCIDENCE OF TUBERCULOSIS UPON 
COMMUNITIES 



CHAPTER XXVIII 
INTRODUCTORY 

ACTUAL experience on a large scale is the final test of 
hypothesis and the surest basis for action. This maxim 
is particularly applicable to public health administration. 
The study of communal experience is therefore of the utmost 
help to the public health service ; but for trustworthy results 
this study must be conducted with a clear recognition of the 
complexity of the material to be examined. With no statistics 
of disease is this caution more necessary than with those relating 
to tuberculosis. 

In the foregoing chapters tuberculosis has been seen to be 
an infectious disease having a variable period of incubation, 
and a course which may extend intermittently or continuously 
over many years. Its prevalence and the death-rate due to 
it may be favoured or hindered by a great variety of personal, 
economic, and sanitary conditions affecting the populations at 
risk. Many of these conditions are themselves composite and 
of great complexity ; and during a considerable part of their 
infective sickness most patients are able wholly or partially 
to keep at work and to migrate from one district to another. 
Without detailing the difficulties which these characters of 
tuberculosis introduce into statistics measuring the prevalence 
of the disease in different communities, or the errors which 
may arise from applying to such statistics the methods appro- 
priate to acute disabling infectious diseases, it suffices for the 
present purpose to recognise that the causation of tuberculosis 
in communities has all the complexity of its causation in the 
individual, with the added complexity due to variations in 
economic and sanitary environment and to the migration of 
infected persons. 

To obtain the best practical results we must simplify this 

complexity. As already seen, a considerable number of in- 

205 



206 THE PREVENTION OF TUBERCULOSIS 

fluences either promote or hinder the spread of tuberculosis ; 
but the preceding chapters could afford little information as to 
their relative importance. Were it possible to adopt all known 
measures of precaution and all the methods of treatment, this 
absence of quantitative information would have merely academic 
interest. Practical administration, however, can afford no such 
wholesale reproduction of laboratory conditions. The amount 
of money and energy available for the public health service, 
though it may fluctuate from generation to generation, is always 
limited ; and of the measures that would aid in the prevention 
or cure of disease only a portion can be put into simultaneous 
operation. Thus any such measure yielding less than the 
utmost value for the resources expended represents an amount 
of avoidable and permitted disease proportionate to the relative 
inefficiency of the measure. It will be seen, therefore, that 
the rational as opposed to the capricious or random selection 
of measures is supremely important to the public health service ; 
and where it can be had, actual experience is the safest and 
final guide. The chief purpose for which the incidence of 
tuberculosis upon communities must now be studied is to learn, 
if possible, from actual experience the relative extent to which 
any or all of the elements of economic and sanitary environment 
have promoted or hindered the spread of the disease. 

Such study is of course beset with the ordinary dangers 
of statistical reasoning, which are much the same as those of 
any edged tools in unskilled hands. In order to learn the 
causes of variations in the incidence of a disease upon com- 
munities, any sets of figures intended to measure this incidence 
must in particular be free from the fallacies due to migration 
of patients, whereby an infection may be acquired in one district 
and be chronicled as disease or death in the statistics of another. 
For this reason among others local statistics have to be handled 
with caution even when they concern acute infectious diseases 
of only a few weeks' duration. Tuberculosis is not only an 
infectious but also a chronic disease, which on the average 
probably extends over years and often escapes recognition during 
a large part of the time. Fallacy is almost inevitable in such 
a case if inferences as to causation are sought from individual 
groups of local statistics. 

If, for example, sanatoria for consumption were established 



INTRODUCTORY 207 

in certain towns or counties of a country otherwise poorly 
provided with them, merely elementary statistical reasoning 
would prevent a comparison between the death-rates of such 
towns or counties, which would attract consumptives beyond 
from outside their bounds, and those of towns or counties without 
sanatoria, with any idea that the comparison could give informa- 
tion as to the effect of sanatorium provision upon the general 
prevalence of phthisis. Similarly the figures of a small rural 
county with a population less than that of many single towns, 
could only be used for inference as to the causes of variations 
in its tuberculosis death-rates if correction were made for the 
migration of healthy persons to towns and of sick persons to 
their country homes, where they can live at a smaller cost and 
nearer their own people. 1 

Nor is it merely its long activity nor its still longer latency 
which demands a wide basis of observation before conclusions 
can be drawn as to the causation of tuberculosis. Its endemic 
prevalence is affected, as we have seen, by factors of sanitary, 

1 The difficulty of forming non-fallacious conclusions from " parochial " 
statistics concerning an infective disease of protracted latency and protracted 
duration may be further illustrated by the phthisis death-rates in tenement 
houses and in the different districts of a large town. It is well known that the 
phthisis death-rate is higher in populations inhabiting one room than in those 
inhabiting dwellings with two or more rooms ; and is greatest in overcrowded 
dwellings of any given size. The association between the phthisis death-rate and 
size of dwelling and overcrowding is complex, and before drawing inferences as to 
the effect on phthisis of the increased infection and lowered resistance accompany- 
ing overcrowding, we should ascertain among other things to what extent the 
inhabitants of these overcrowded tenements drifted into them after and perhaps 
because they had become consumptive. Similarly, in comparing different 
districts of a large town or even small towns with each other, allowance has 
to be made for the influx of consumptives into poorer districts as they go down 
in the social scale. If this can be done, — and it implies a complete knowledge 
of each patient's history and of the duration of the latent period of his disease, — 
it has further to be noted that inasmuch as the opportunities for infection by 
phthisis vary enormously in different districts, the effect of measures against 
infection must correspondingly vary. We must therefore either compare 
the influence of such measures on large masses of population in whom this source 
of error is likely to be equalised, or on small aggregations having a like com- 
position. It is evident, for instance, that efforts against infection may have had 
a greater effect on the death-rate from phthisis in a district whose death-rate 
from this disease is still 2 per 1000 than similar efforts in another district of a 
different social stratum whose death-rate from phthisis is only 1 per 1000. For 
the above and other reasons, local statistics of phthisis cannot be used without 
fallacy, unless corrections are made which only the most intimate investigation 
will render practicable. 



268 THE PREVENTION OF TUBERCULOSIS 

including social and economic, environment, which themselves 
are of high complexity and largely interdependent. Such 
phenomena may be unrecognisable in experience on a small 
scale. 

To eliminate or minimise the effects of migration and com- 
plexity we must study communities in which the balance between 
immigrant and emigrant cases is small relatively to the total 
volume of disease, and which are so large as to allow the operation 
of complex phenomena to become evident. The use of figures 
relating to large communities is further commended for the 
study of tuberculosis because their size reduces the chance 
of the results being determined by some local or accidental 
feature among the complex relevant conditions of environment. 
The experience of smaller communities can only be taken either 
as hints which may possibly be confirmed by other information, 
or as illustrations of the manner of action of influences of which 
the existence has been demonstrated independently. 

In the investigation which is summarised in the following 
pages it has been found possible to obtain significant results 
as to the causes of the variation in death-rates from tuber- 
culosis by grouping these rates for given communities and 
periods with the figures which represent for the same com- 
munities and periods the variations of sanitary and economic 
environment, thus disclosing what the figures can tell of the 
relationship between the two sets of phenomena. The following 
chapters include the results of the comparison of such of these 
data as are available. It will be found that improvement 
in general communal health and in the individual factors 
affecting it has not always corresponded with the reduction of 
tuberculosis, although the statistical evidence shows a probable 
connection between most of these factors and the disease. If 
no constant correspondence had appeared between the course of 
tuberculosis and any element of environment, no conclusion 
could have been obtained from the statistical study of communal 
experience, and we should have been left to draw the most 
probable inferences we could from the facts stated in Part I. 
Such a result would not have been surprising. Communal 
experience has to be studied not in the orderly sequence of 
individual influences provided in laboratory experiment, but in 
the simultaneous and highly complex combinations of influences 



INTRODUCTORY 209 

found in communal life. In these combinations nothing is 
more common than to find that the number of unknown 
quantities is too great and the facts too few to permit of an 
approximate estimate of the respective values of the unknowns. 
It will be found, however, that the course of tuberculosis has 
followed that of one element of sanitary environment, namely, 
the institutional segregation of tuberculous patients. From an 
administrative standpoint, this result has considerable con- 
sequences. It is desirable therefore to examine in detail the 
evidence as to each of the elements of sanitary environment 
concerned. 

In most cases the figures relating to phthisis have been 
taken as representing tuberculosis, as they are recorded more 
fully, and are based on diagnosis which is more accurate than 
that of total tuberculosis. In almost all cases the incidence 
of the disease has had to be measured by its death-rate. 



14 



CHAPTER XXIX 

TUBERCULOSIS AND GENERAL HEALTH IN VARIOUS 
COMMUNITIES: VIRULENCE, NATURAL SELECTION, 
AND DECADENCE 

THE first teaching of communal experience on this subject, 
the evidence for which will be outlined in the present 
chapter, is that the control of tuberculosis is not merely a 
question of the improvement of general health and of sanitary con- 
ditions. No result could be more important or more encouraging 
for practical purposes. Those concerned in the service of public 
health know how much remains to be done before it can be said 
to have done its best. If general sanitary conditions are under- 
stood — as they are in this connection — to include all those con- 
ditions which affect general health, the task that remains to be 
done is indefinitely great. The improvement of conditions of 
housing, abolition of overcrowding, the enforcement of a higher 
standard of specific and general cleanliness, the removal of 
injurious conditions of work, whether in mine, factory, 
workshop, shop, office or home, the promotion of reason- 
able recreation in our towns, the removal of hindrances to 
temperance and thrift, all of which come within the range of 
the task, illustrate the vastness of the physical, economical, 
and even moral problems involved, and of their importance 
to national life, happiness, and efficiency. The cultivation of a 
popular sanitary conscience is therefore an object of supreme 
importance to the well-being of any community, and the con- 
nection between tuberculosis and bad general sanitary conditions 
can be utilised to the full extent in stimulating this conscience. 

But though this connection is far-reaching and intimate, it 
must not be allowed to obscure other influences which have 
had more direct effect on tuberculosis. There are few sanitary 
improvements that do not in some measure tend to hinder the 
spread of tuberculosis. This fact is evidenced so strongly and 



TUBERCULOSIS AND GENERAL HEALTH 211 

in so many ways, that the doctrine that the control of tuber- 
culosis must be sought not by measures specially directed against 
the disease, but by improvement in general sanitary environment, 
has been adopted by many as the final formula on which the 
control of tuberculosis must be based. The correctness of such 
a doctrine does not follow necessarily from the many facts illus- 
trating the connection between tuberculosis and sanitary environ- 
ment ; and an examination of the actual experience of large 
communities shows that it is contradicted by the facts. To 
those who hope for the extirpation of the disease, this result is a 
matter of congratulation. The demonstration of the formula 
which says that tuberculosis is to be conquered mainly through 
improvement in general sanitary conditions, and not through 
special measures acting in conjunction with them, would have 
been full of profound discouragement and the sickness of hope 
deferred. If the control of tuberculosis must await the general 
perfection of sanitary conditions, including the economic and 
moral circumstances which form an essential part of them, no 
reasonable limit could be put to the time which must elapse 
before tuberculosis disappears. 

The belief that no practicable special measures exist by which 
the disease can be controlled more rapidly and directly than 
by measures of general sanitary reform, is not supported by past 
experience in regard to other infectious diseases which have been 
extirpated wholly or in part. Cholera, typhus and enteric fever 
in England, and small-pox in Germany have been stamped out 
or greatly diminished by adding to the necessarily partial 
measures of general sanitary reform a complete application of such 
special measures as actual experience has shown to be efficient. 
Tuberculosis can be extirpated similarly, if similarly the slow 
effect of only gradually improving sanitary circumstances be 
supplemented by special measures having a more rapid and 
specific effect on the disease. If such measures are contained 
in the general body of sanitary improvement, they require to 
be dissected out and identified before they can be applied with 
rapidity and completeness. 

There has been no constant relation between improved 
general sanitary circumstances and reduction in tuberculosis. 
The most definite expression of the course of general sanitary 
(including social) improvement in the gross and of tuberculosis 



212 



THE PREVENTION OF TUBERCULOSIS 



is to be found in the course of the death-rate from all causes 
other than tuberculosis and the death-rate from tuberculosis. 
For the reasons explained previously, the death-rate from tuber- 
culosis will be taken to be measured by that of phthisis. 

In Table XLII. the death-rates from pulmonary tuberculosis 
and from all other causes in various countries and capital cities 
are given for 1881-85 an d f° r 1901-03 or 1901-02. These 
relatively recent periods are taken for comparison, because in 
some instances earlier figures are unobtainable. 

Table XLII 









A. 


B. 






Death-rate 
from all Causes 
except Phthisis. 


Death-rate from 
Phthisis. 


Percentage 
Change in 


1881-85. 


1901-03. 


1881-85. 


I9OI-O3. 


A. 


B. 


England and Wales . | 1 7*97 


14*94 


-s, 


1-23 


- 17-0 


-32-7 


Scotland . 


I7'45 1576 


2'II 


1 '47 


- 9-9 


-30-3 


Ireland . 






15-90 ! 15-45 


2-08 


215 


- 2-8 


+ 3-4 


Norway . 






1575 


12-58 


i-39 


1 92 


-20*4 


+ 38-I 


Prussia . 






22-29 


17-90 


3-n 1 


I-93 1 


-197 


-37*9 


Massachusetts 






16-68 


1477 


3-14 


1-67 


-115 


-46-8 


Paris 






19-99 


I4-I5 


4-41 


3'65 


-29-3 


-I7'2(?) 


Berlin . 






21-38 


1376 


3'32 


2*04 


-33"7 


-38-5 


Copenhagen 






19-38 


14-81 


2-89 2 


1-38 


-23-7 


-52*2 


London . 






18-78 


I5-38 


2*20 


1 -65 


- 19-2 


-25-0 


Manchester 






18-76 


16-34 


2*42 


2'OI 


-13-1 


-16-9 


Edinburgh 






i6'34 


I4-74 


1-89 


1,51 , 


- 9*5 


-20*1 


Glasgow . 






22-34 


17-83 3 


3-14 


i-68 3 


-20'0 


-46-5 


Dublin . 






24-25 


23-02 


3'55 


3-28 


- 5*2 


- 7-6 


Belfast . 






20-32 


18-32 


378 


3'o8 


- IO'2 


-i8-5 



1 Tuberculosis. 



1880-84. 



1901-04. 



It will be noted that in all cases the general death-rate apart 
from phthisis has declined ; as has also the phthisis death-rate 
in all except Ireland and Norway. 

The increase in Ireland is really greater than it seems. Emi- 
gration, as will be seen later (p. 217), has altered the age and 
sex distribution of the population by removing a large part of 
the young and middle-aged, among whom most deaths from 
phthisis occur ; and when the figures are corrected for age and 
sex distribution, the true increase of phthisis on the assumption 
of constant age and sex distribution is seen to be really larger 



TUBERCULOSIS AND GENERAL HEALTH 213 



than the figures show. Thus when the crude phthisis death- 
rate in Ireland for 1891, which was 19*3, is corrected for age 
distribution of population so as to make it comparable with that 
for 1901 (21 '5), it becomes 177 per 10,000 ; and the crude increase 
of 12 per cent, becomes a corrected increase of about 22 per cent. 
A very high decrease of general death-rate apart from phthisis 
is shown by Norway, which shows increase of its phthisis rate. 1 
It will be noted also that in every country and city in which 
a decrease of phthisis has been shown this decrease is greater 
than that of the death-rate from all other causes. This 
disparity is of very variable extent, but except in Dublin and 
Manchester the disparity between the two diseases is always 
great. Table XLIIL, calculated from Dr. Tatham's data for 
England and Wales, makes a similar comparison analysed in 
detail into sexes and ages. 

Table XLIII. — England and Wales 

Perce?itage Decline or Increase of Death-rate when the experience of 

1861-70 is compared with that of 1 896-1900 













Males. 


Females. 


At Ages 


General Death- 




General Death- 






rate minus 


Phthisis. 


rate minus 


Phthisis. 




Phthisis. 




Phthisis. 




0- 


-14 


-60 


-16 


-65 


5- 










-49 


-67 


-45 


-58 


10- 










-46 


-68 


-42 


-61 


15- 










-32 


-59 


-40 


-63 


20- 










-34 


-52 


-36 


-62 


25- 










-28 


-43 


-29 


-58 


35- 










-15 


-25 


-14 


-46 


45- 










- 1 


-17 





-44 


55- 










+ 6 


-19 


+ 2 


-40 


65-75 








+ 3 


-24 





-36 


All A{ 


jes . 








-M 


-38 


-14 


-54 

i 



1 The official figures relating to Norway, by reason of the increased complete- 
ness of certification, show a higher increase than is likely to have occurred in 
fact ; but no reasonable correction in this respect would show decline of 
phthisis during the period in question ; and the argument developed in the 
text — which would remain the same if even a stationary death-rate from 
phthisis were substituted for the increase shown by the official figures — is 
unaffected. So far as England and Ireland are concerned the figures may be 
accepted within narrow limits of error. 



214 THE PREVENTION OF TUBERCULOSIS 

It is clear from this table that in England, as in the instances 
in Table XLII. to which reference has been made, the reduction 
of the phthisis death-rate is enormously greater than that of the 
general death-rate from all other causes ; and the discrepancy 
is especially great at the working years of life in which phthisis 
causes its heaviest death-rate. If phthisis had shared only to 
an equal extent in the general reduction of mortality, a pre- 
sumption would have arisen that the improvements in general 
sanitary conditions which have been operating to reduce the 
general death-rate, such as higher wages, cheaper food and 
clothing, improved sanitation, and other allied influences, are 
in themselves a sufficient explanation of the reduction of phthisis. 
The above figures show that, however much these influences 
have contributed to the reduction, they do not explain it suffi- 
ciently, unless it be assumed that phthisis is far more susceptible 
to the operation of these influences than other diseases. For this 
view there is no evidence, and I am not aware that it has been 
put forward. On the English figures, therefore, the variation 
in the phthisis rate must accordingly be taken to have involved 
co-variations in some phenomenon or group of phenomena 
which have had no material effect on the general death-rate. 

The same conclusion results from the figures of other countries. 

Where phthisis has been reduced, the reduction has been not at 

the rate of the reduction of the general mortality but at a much 

faster rate. The extra rapidity of the decline of phthisis is not a 

fixed part of the reduction of the general mortality, but a part 

which varies widely from country to country ; in two countries 

an improvement in general mortality has been accompanied by 

an actual increase in mortality from phthisis, and in one of them 

both the improvement in general sanitary conditions and the 

increase in the death-rate from phthisis have been exceptionally 

large. Thus in the experience of a considerable number of 

countries, the conditions improving general health have not 

had any constant effect on the prevalence of tuberculosis, and 

in Norway, in which an exceptional improvement in general 

health has occurred, it has been accompanied by increase 

in mortality from tuberculosis. It follows therefore that, 

whatever may have been diminishing tuberculosis, improvement 

in general sanitary and social circumstances has not been the 

principal cause, and that an influence or influences of more 



TUBERCULOSIS AND GENERAL HEALTH 215 

powerful and rapid operation must have been at work in the 
communities examined. 

So far as this comparison carries us, variations in the death- 
rate from tuberculosis might be wholly independent of any 
sanitary conditions. From what has been seen in Part L, this 
alternative is clearly incorrect, seeing that many conditions 
affecting general health are known independently to have a 
powerful and direct effect on tuberculosis. Simultaneously, 
however, with the operation of general sanitary improvement 
other influences may have been at work independent of sanitary 
conditions or not dependent on them directly ; these influences 
may have done more to modify the prevalence of tuberculosis 
than any influences of sanitary environment, and it is con- 
ceivable that the control of tuberculosis is not to be expected 
primarily through measures of further sanitary reform, whether 
general or special. 

The three influences not necessarily associated with general 
sanitary environment which have been suggested as having 
possibly operated in different communities to produce the 
recorded variations in the death-rate from tuberculosis are : an 
attenuation of the virulence of the infecting organism ; a process 
of weeding-out of the more susceptible population; and an 
exactly contrary process of survival of the unfit and consequent 
decadence of the average population. 

Variations of virulence in the specific micro-organisms are 
known to have occurred with some infectious diseases. They 
have been demonstrated by variations in the type as well as 
the severity of the clinical symptoms, and hitherto only when 
such variations have been demonstrable has a variation in the 
virulence of the disease been suggested. There is no evidence 
that such a variation has occurred in the case of tuberculosis ; 
and the suggestion is made in the teeth of a considerable volume 
of evidence to a contrary effect. The clinical types of the 
disease, as recorded in the contemporary descriptions of Graves, 
Watson, Walshe, Flint, and others at the beginning of the period, 
show the same varieties of type and duration as are now seen. 
No well-marked distinction has been established between the 
types of tuberculosis in different countries. Though consump- 
tives probably live longer now than they did formerly, it must 
be remembered that the rational treatment of the disease has 



216 THE PREVENTION OF TUBERCULOSIS 

only become general in recent years. The assumed attenuation 
of virulence which is held to be displayed in one country because 
its tuberculosis bill has decreased, can scarcely be assumed 
to have existed simultaneously in neighbouring and inter- 
communicating countries in which the disease has increased, 
notwithstanding the fact that the clinical types of the disease, 
so far as can be ascertained, have remained unchanged in both 
countries during the whole period under examination. All the 
evidence available tends therefore to show that outside bacterio- 
logical laboratories no change of virulence has occurred in the 
bacillus of tuberculosis, and the only evidence from which it 
has been sought to infer such a change is the decrease of the 
prevalence of tuberculosis in certain countries, the actual 
phenomenon to explain which this otherwise unsupported 
assumption has been made. 

The hypothesis that the reduction of the disease may be 
due to elimination of susceptible strains of human beings depends 
similarly on the mere fact that it is consistent with the decrease 
which has occurred. The evidence of the transmission of sus- 
ceptibility has not been sufficient to show that this trans- 
mission occurs so frequently as to be a predominant factor 
in the transmission of the disease. On the other hand, there 
is abundant evidence to show the existence of susceptibility, 
not inherited and permanent, but temporary and acquired 
through circumstances of environment. It is equally clear that 
the liability to infection is affected by extent of dose, and that 
a considerable proportion of the population in contact with 
tuberculous patients is exposed to extreme and prolonged 
infection. Persons placed in these circumstances would acquire 
infection with greater certainty than others, and when they 
were children of tuberculous parents this occurrence would be 
practically indistinguishable from inherited susceptibility, and 
has doubtless often been regarded as such. Even if the inherit- 
ance of susceptibility had been demonstrated as a common 
occurrence, it could only explain the decreases that have 
occurred in most countries on the assumption that the sus- 
ceptible victims had a special infertility. The mere death of 
susceptible patients at the end of a chronic infectious disease 
of long duration and extending most often into middle life can 
have had little or no effect on the susceptibility of the children 



TUBERCULOSIS AND GENERAL HEALTH 217 

of these patients, unless these children are on the average 
much less numerous than the children of entirely healthy 
stocks. Although there appears to be a difference between the 
two stocks in this respect, it does not suffice to explain results 
already obtained. 

In considering the suggestion that decadence has been 
responsible for the increase of phthisis, where this has occurred, 
we may turn again from the discussion of interesting but quite 
unverified hypotheses to the more sober study of actual experience. 
The country in regard to which this has been oftenest urged is 
Ireland. The undoubted general poverty of the country makes 
the suggestion prima facie plausible ; and unhappily plausible 
hypotheses whose face is their fortune are often accepted because 
no one is concerned to ask for more solid credentials. If the 
instructive experience of Ireland in regard to phthisis is to be 
explained by an ill-defined influence of which the control is 
hard and uncertain, the prospect of mastering the endemic 
prevalence of phthisis in Ireland would be postponed to an 
extent that would discourage administrative reform directed 
against more definite causes. In itself, therefore, the alleged 
decadence of the Irish people in Ireland deserves careful con- 
sideration ; and the study is not the less desirable because, 
as we shall find, the existence of a general average decadence 
of population in Ireland is, so far as phthisis is concerned, a 
wanton speculation contradicted directly by the facts. 

The suggestion is that the long stream of emigration from 
Ireland has left behind it a physically inferior population of 
excessive susceptibility to phthisis. This emigration reached 
its height in 1851, when over 34 per 1000 of the entire popula- 
tion left their country ; but it has continued up to the present 
time, still averaging 9 per thousand per annum during the 
present century. That the effect of this emigration has been 
to leave a decadent residual population is merely an assumption, 
which at the outset is discredited to some extent by the fact 
that the birth-rate in Ireland (corrected for the number of 
women at child-bearing ages and for the number of married 
women) has increased from 35*2 in 1881 to 36*1 per thousand in 
1901, against a decrease in England from 347 to 28'4. It is 
discredited further by the fact that the majority of those driven 
from Ireland were among the poorest, and these through their 



218 THE PREVENTION OF TUBERCULOSIS 

poverty must have been the least fit. The cottiers and farm 
labourers on the smallest holdings emigrated in the largest 
numbers ; those who remain are children of the families who 
could resist the stress of famine and evictions, and who in recent 
years have been living in progressively better conditions than 
their predecessors. Even a comparative examination of the 
present population does not show an appreciable difference in 
the communal susceptibility to phthisis between rich and poor 
towns. Belfast is the part of Ireland which probably has 
suffered least from emigration, and is commercially the most 
prosperous. Yet its death-rate from phthisis was 307 per 
100,000 in the five years 1901-06, as compared with 315 in the 
much poorer and more crowded city of Dublin. 

These considerations, though much more weighty than the 
general speculation by which decadence in the Irish population 
is alleged, are still to some extent inferential. Fortunately it 
is possible to settle the question definitely by actually following 
the emigrated population and comparing their susceptibility 
with that of the residual Irish. 

The chief emigration from Ireland has been to the United 
States. If the cause of the increased death-rate from phthisis 
in Ireland is the physical inferiority of its residual population, 
the death-rate from phthisis of the Irish population in the 
United States ought to be lower than that in Ireland. It is 
practically certain that no disturbing influence in such a com- 
parison is exercised by greater well-being or better sanitation 
or housing in Ireland than in the United States. The American 
Census Report for 1900 gives the death-rates from phthisis in the 
registration area and its subdivisions among whites in the 
census year, classified according to the birthplaces of the mothers 
of the deceased. For all inhabitants of these States the phthisis 
death-rate in 1900 was 113, for English (defined as above) 135, 
for Scotch 173, for Germans 167, for Irish 340. The difference 
is seen both in cities and in rural districts, the phthisis death- 
rate of the Irish in rural districts being 239, as compared with 
a general rate of 108. In Ireland in the same year the phthisis 
death-rate was 226 and in Dublin 346. These are death-rates 
uncorrected for age distribution. For such correction we turn 
to the vital statistics for the city of Providence, Rhode Island, 
which are well known to be among the most trustworthy in 



TUBERCULOSIS AND GENERAL HEALTH 219 

the United States. Dr. Chapin, the city registrar and medical 
officer of health, has published statistics corrected for age dis- 
tribution which enable a corrected comparison to be made. 
He applied the death-rate from phthisis in Ireland in 1901 for 
sex and age periods to the population of Providence in 1900 
born of Irish mothers. " It was found that the theoretical 
mortality from phthisis of this element of the population (of 
Providence) according to these (the Irish) data was 258 per 
100,000 living. The actual rate for the period 1896-1905 was, 
however, 339. The mortality from phthisis of the Irish in 
Providence is therefore 81 per 100,000, or 31*4 per cent, more 
than the mortality of the Irish in Ireland." 

It is clear therefore that, so far from emigration having 
increased the communal susceptibility of the residual Irish 
population to tuberculosis, the Irish in Ireland have a substan- 
tially less susceptibility than their emigrated brethren, and that 
this difference is not due to any inferiority in the environment of 
the emigrated population. The inability of extreme poverty 
to produce a high death-rate from phthisis in a rural popula- 
tion is strikingly shown in the County of Mayo (p. 180). 



CHAPTER XXX 

TUBERCULOSIS IN URBAN AND IN RURAL 
COMMUNITIES 

IN the present and the succeeding chapters we have to 
consider the experiences of large communities over long 
periods of time, and to compare the variations in the 
figures measuring the incidence of tuberculosis and those, where 
they can be obtained, which measure the variations in the element 
of experience under consideration. 

To avoid misapprehension, a preliminary remark is necessary 
as to the years which should be compared. The effect of altera- 
tion in environment does not begin to appear till after a certain 
interval. If the element in question operates solely by diminish- 
ing infection, the interval must be that which represents the 
minimum period of incubation and latency. This interval 
cannot be stated with any exactness, and it is still less possible 
to state the interval which would have to elapse before an altera- 
tion which modified resistance of the community to infection 
would produce an evident effect. Strictly speaking, the figures 
which represent alteration in environment should be compared 
with those which represent incidence of tuberculosis at a period 
later by this interval. It is fortunate that the run of these figures 
in the present inquiry, as might be expected with a disease of 
long incubation and latency such as tuberculosis, is such that 
changes from one quinquennium to another are not abrupt ; 
and in a sufficiently long series of pairs the results of identical 
quinquennia can therefore be grouped with substantially the 
same result as if the element of environment were represented 
by the figures of the next quinquennium or the next but one. 

Communities may be grouped most broadly according as they 
are urban or rural, and the experience now to be examined shows 
the remarkable result that while urban conditions have pro- 
moted the prevalence of tuberculosis, they have rarely sufficed 



URBAN AND RURAL COMMUNITIES 



221 



to prevent extraordinary decreases in the disease, nor in all 
cases have rural conditions sufficed to prevent increases. Town 
life on the whole is less healthy than rural life. Some evidence 
of the unquestionable correctness of this belief may be gathered 
from an inspection of Table XLIL, p. 212 ; and this difference to 
the disadvantage of the towns is seen in tuberculosis as well as 
in other diseases. This result may be checked with the help of 
two valuable tables by Dr. Tatham, published in the Registrar- 
General's Report for 1904, from which the following table is 
extracted and calculated. This table deals with an estimated 
urban population of 18,262,173, including the chief industrial 
centres, and a rural population of 4,327,835, including only a 
few unimportant towns and villages. The death-rates have 
been corrected for variations in the age and sex distribution of 
the respective populations. 



Table XLIV. — England and Wales 
Selected Urba?i and Rural Counties of the Registrar-General \ 1898-1903 



Corrected Death-rates per iooo of Population. 



Males. 



All Causes 
except Phthisis. 



Urban Counties 
Rural , , 



Urban Counties 
Rural 



[8-4 
[35 



137 
100 



Phthisis. 



Females. 



All Causes 
except Phthisis. 



r66 
1 '27 



i7'5 
i3'2 



Phthisis. 



Proportional Figures (Rural rates = ioo) 



131 

100 



133 

IOO 



III 

1-07 



104 
100 



These collective results show no less strongly than those 
of individual countries and towns that town life is unhealthy as a 
whole, and is favourable to the prevalence of phthisis. If they 
could be corrected for the fact that the towns attract the robust 
and strong, while the weakly tend to remain in and return to 
rural districts, the extent of this mischief would be exhibited 
more strikingly and even more accurately. In the absence of 
powerful countervailing influences, those countries would there- 
fore be expected to have suffered most from phthisis and to have 



222 



THE PREVENTION OF TUBERCULOSIS 



shown most marked increase in the disease in which the excess 
of urban over rural population has been the largest and the most 
progressive. 

An examination of the facts shows, however, that the exact 
contrary has occurred. 

Table XL V. exhibits for certain countries the distribution of the 
population between town and country at or near the beginning 
and end of the period under review. The definition of " urban " 
varies somewhat in different countries, but in each country 
remains the same throughout the period under examination, so 
that the results are comparable. The corresponding phthisis 
rates are included in the table, and the changes in the death- 
rates are expressed as percentages of the earlier figures. 



Table XLV 











■a 














c 




m 










S.2 


1* 


O 










O fcJD 





' . 




Percentage 




w 

2 O 
• j 


O c M O 


c.js 

O en 

"■S3 

3 ^ 


1 11 




of Total 


Phthisis 


1— ( c/) 


c-2 "S rt 




S-i rt 




Population 
who were 


Death-rate. 


to cd 


<J ,2 *-' <u 

O o.'O c5 

> Q O "" 








Urban in 




^ 


'-C fL, 'S bO 




Q'S 








Ph 


Rel 

Urban 

cent P 

bei; 


C 

Ph 


"55 Gi 

3g 














Ph 








1866- 


1901- 












1861. 


1901. 


1870. 


1903. 










England and Wales . 


63 


77 


2'4S 


1-23 


22 


100 


-50 


100 


Scotland . 


52 


70 


2'59 


I -48 


35 


91 


-45 


120 


Ireland 


20 
1864. 


3i 
1895. 


1-82 


2-15 


55 


40 


+ 18 


i75 


Prussia 


30 
1865. 


4i 

1891. 


3-20 1 


I-94 1 


37 


53 


-39 1 


? 


France 


29 
1840. 


38 
1890. 


4*57 2 

Mass. 


3-65 2 


3* 


48 


?none 


297 


United States . 


8 
1865. 


29 
1891. 


3*65 


1-67 


262 


* 


-5o 


136 


Norway . 


16 


21 


i'32 3 


1-92 


3i 


27 


+ 46 


156 



1 Between 1877-80 and 1901-03. 2 Paris. 3 In 1876-80. 

More recent data as to urbanisation are contained in Table 
XLVI. from Dr. Shadwell's work (1905, vol. ii.). . * 



URBAN AND RURAL COMMUNITIES 



223 



Table XLVI 

Percentage of the Population of Great Towns having over 100,000 
Inhabitants to the Entire Population of each Country 



England. 


Germany. 


United States. 


1881. 


1901. 


1880. 


1900. 


1880. 


1900. 


316 


35'o 


7'2 


l6'2 


14*6 


18-8 



In context with these results reference may be made again to 
Table XLIV. It will be noticed that the excess of the general 
death-rate in urban counties over that in rural counties is 
approximately equal for males and females (37 and 33 per cent.), 
while the excess of phthisis in urban counties is 37 per cent, 
among males and only 4 per cent, among females. In Birmingham 
and Sheffield the female death-rate from phthisis, as shown in 
Fig. 13, p. 166, is actually lower at most ages than that in England 
and Wales as a whole. When it is remembered that women 
spend much more time at home than men, and that their experi- 
ence must reflect more than that of men the influence of home 
environment, it becomes clear that the influence of urban life 
on phthisis is specifically different from its effect on other causes 
of mortality in the aggregate. 

The experience summarised thus shows that enormous changes 
have occurred both in the extent of urbanisation and in the pre- 
valence of phthisis in each of the countries examined, and that 
in every country town life has been associated with a greater 
prevalence of tuberculosis than has country life. There has 
been everywhere a heavy increase of urbanisation, which in 
spite of the larger amount of phthisis in towns has been accom- 
panied in most countries by a large reduction in the prevalence 
of phthisis both in town and in country ; indeed, the countries 
with the most town life have suffered actually the least from 
phthisis. It follows therefore that, powerful as has been the 
influence of town life in assisting the prevalence of tuberculosis, 
some other more powerful influences have been in operation in 
most countries to restrain the disease. 



CHAPTER XXXI 
TUBERCULOSIS IN OVERCROWDED COMMUNITIES 

THE next fact to be extracted from communal experience 
is that even overcrowding has been unable to exert a 
predominating influence on the course of tuberculosis. 
Overcrowding is the most mischievous factor of town life. Its 
operation even in country districts must be detrimental ; and 
in towns the privation of light and air which it usually entails 
must add greatly to its depressing effect. So much is certain 
from general considerations, and it is equally certain that tuber- 
culosis as well as other diseases must be susceptible to the influ- 
ence of overcrowding. In the last chapter we found as a fact in 
international experience that town life, though tending power- 
fully to increase the prevalence of tuberculosis, has not sufficed 
to cause an increase in the face of other countervailing circum- 
stances to be considered subsequently. It is unnecessary or 
impracticable to examine separately certain of the factors of 
town life. We have seen in Part I. that subsoil drainage is 
not likely to have been a factor of primary importance for this 
purpose. The substitution in town life of industrial for agri- 
cultural conditions is so essential a part of urbanisation that a 
separate investigation of its changes could give no different 
results from those obtained in the last chapter. The ameliora- 
tion of industrial conditions in regard to dust, ventilation, 
etc., is not expressed directly in any recorded figures; to some 
extent an indirect expression may be found in the evidence which 
will be considered as to sanitary education. Neither can a 
direct expression be obtained for the changes in provision of 
light and air ; but indirectly they are covered by the changes in 
overcrowding, which fortunately are recorded sufficiently for 
the present purpose. It is in overcrowding that the most 
vicious results of town life must be sought ; and they deserve 
very careful consideration. 



OVERCROWDED COMMUNITIES 



225 



The difference in total housing accommodation between 
urban and rural communities in England and Wales may be 
seen broadly in Table XLVII. 

Table XLVII 

1 90 1. — Of the Total Population in Urban and Rural Districts respectively \ 
the Percentage living in each Class of House was as follows : — 





Tenements containing 


One 

Room. 


Two 

Rooms. 


Three 
Rooms. 


Four 
Rooms. 


Five or 

more 

Rooms. 


Total. 


Urban Districts 
Rural , , 


2*0 
o*2 


7 '4 
3*9 


10-3 
8-i 


21*2 
24*0 


59*1 
63-8 


ioo-o 
100 -o 



Thus, compared with rural districts, ten times as large a pro- 
portion of the total population lived in one-roomed tenements 
in urban districts, and nearly twice as large a proportion lived 
in two-roomed tenements. 

The difference in overcrowding between urban and rural 
communities in England and Wales is shown in Table XLVII I. 
A tenement is reckoned as overcrowded in which on an average 
each room, whether bedroom or living room, is occupied by 
more than two persons. 

Table XLVIII 

1 90 1. — Of the Total Population in Urban and Rural Districts respectively, 
the Percentage Overcrowded in Tenements of four Rooms and under was 
as follows : — 





Tenements containing 


One 
Room. 


Two 
Rooms. 


Three 
Rooms. 


Four 
Rooms. 


Urban Districts .... 
Rural ,, .... 


0-95 
0*09 


3-07 
1 '54 


2-63 
1-98 


2*25 
2-23 



This table shows that ten times as many one-roomed 
J 5 



226 



THE PREVENTION OF TUBERCULOSIS 



tenements, and twice as many two-roomed tenements were 
overcrowded in urban as in rural districts. 

Nothing could be more conclusive than these results as to 
the difference both in housing and in overcrowding between 
urban and rural districts. Compared with rural districts, 
towns in 1901 had ten times as large a proportion of the total 
population housed in one-roomed tenements ; and of the popu- 
lation so housed in one-roomed tenements, ten times as many 
were overcrowded in towns as in country. Nearly double 
the proportion of town population inhabited two-roomed 
tenements as of country population, and of these twice as many 
were overcrowded in town as were in the country. Compared 
with 1891 marked improvement had occurred in overcrowding 
in towns, but very much more in the country districts. By 
the side of these improvements have gone, as we have seen, 
marked decreases in the prevalence of phthisis, and by the side 
of the disparity in housing between town and country there 
is the disparity already shown in the urban and rural phthisis 
death-rate for males. The female death-rate, which would be 
most strongly affected by home conditions, is substantially the 
same for towns as for country, in spite of the enormous difference 
in housing and overcrowding. 

In the case of Ireland, the relations between overcrowding 
and tuberculosis are masked completely. 

It has already been seen (Fig. 31 and Table XLII.) that the 
death-rate from phthisis in Ireland has increased. This higher 
death-rate has been associated with a progressive improvement 
in conditions of housing. The facts on which this statement is 



Table XLIX 
Percentage of Different Classes of Houses in Irela?id 



\ 


1841. 1861. 


1881. 


1891. 


I90I. 


1st class 
2nd ,, 
3rd „ 
4th „ 


3-0 
19-9 
40-1 
37-0 


8'3 
37'6 
457 

8-4 


97 
46-9 
39-2 

4'2 


IOC 

53-6 
33-8 

2'I 


Ill 

59'3 
28-4 


IOO'O 


IOO'O 


IOO'O 


IOO'O 


IOO'O 



OVERCROWDED COMMUNITIES 



227 



based (Table XLIX.) are taken from a paper by Dr. (now Sir T.) 
Matheson, Registrar-General for Ireland (1903). 

The fourth class of houses comprises chiefly houses of mud 
or other perishable materials, having only one room and window ; 
the third class, a rather better class 
of house, having two to four rooms 
and as many windows ; the second 
class is equivalent to what would be 
considered a good farmhouse having 
five to nine rooms and windows ; 
and the first class comprises all 
better houses. The changes in the 
proportion of these different classes 
of houses are set forth more clearly 
in Fig. 19. 

Sir T. Matheson's conclusion is 
that " the material improvement in 
the housing of the people of Ireland 
since 1841 is very satisfactory, but 
that there is still much to be accom- 
plished.' ' 

Comparing Ireland with England 
and Scotland, Sir T. Matheson finds 
that in 1901 in England 3-6 per 
cent., in Ireland 87 per cent., and 
in Scotland 17-5 per cent., of the 
total dwellings consisted of only 
one room ; further, that the per- 
centage of the total population living 
in these one-roomed tenements and 
having five or more persons in each 
tenement was 0*15 in England, 178 
in Ireland, and 3*27 in Scotland. FlG - IQ 
Thus Scotland has more than double 
the proportion of one-roomed tene- 
ments that Ireland has, and in nearly twice as many of these 
the number of occupants exceeds five. 

Contrasting these facts with the corresponding phthisis 
death-rates, we see that some counterbalancing influence or 
influences have prevented Ireland from obtaining any lowering 




Showing steady im- 
provement in Housing Condi- 
tions in Ireland. 



228 THE PREVENTION OF TUBERCULOSIS 

of its phthisis death-rate along with its improvement of housing, 
and have enabled Scotland with a larger proportion of single- 
roomed tenements and more overcrowding than Ireland to secure 
a lower death-rate than the latter country. 

In Paris the conditions of housing are extremely bad, and 
the phthisis death-rate is high and probably almost stationary. 
Over one-fourth of the total families were housed in single 
rooms, and nearly one-third in tenements of two rooms, and 
more than three-fourths in three rooms or less. 

Official figures are available for Berlin for every five years 
from 1861 to 1895. From these we learn that the number of 
one-roomed tenements out of every 100 tenements of all sizes has 
been about 50 throughout these forty-five years, while the number 
of two-roomed tenements in the same interval has only varied 
from 24 to 27 per cent., of three-roomed tenements from 10 to 
12 per cent., and of larger tenements from n to 12 per cent, 
of the total number. A very large proportion of the population 
of Berlin live in block-dwellings, and the average size of these 
block-dwellings has increased. Doubtless the standard of these 
dwellings as to cleanliness, as elsewhere, has improved ; but it 
is a remarkable fact that although half the families in Berlin 
live in single rooms, the death-rate from phthisis in that city 
has declined 45 per cent, between 1876-80 and 1901-03. 

In Norway the census returns for the towns show that in 
1 891 the proportion of dwellings comprising one room was 42*4, 
and comprising two rooms was 27*6 per cent, of the total 
dwellings, while in 1900, the proportion of one-roomed dwellings 
had decreased to 28*1 per cent., and of two-roomed dwellings 
had increased to 34*5 per cent, of the total dwellings. 

In New York a similar story has to be told. Dr. Hermann 
Biggs (1903-04, p. 191) says :— 

There has been a more rapid fall in the tuberculosis death-rate in 
New York City than in any great city in the world, and this notwith- 
standing the fact that the conditions in many respects are much more 
unfavourable, because of the very dense population in the great tenement- 
house districts of the city, and the large element of foreign born popula- 
tion. It should be remembered that in no city of the world is there 
such a density of population as exists in many of the wards of the borough 
of Manhattan. 

As illustrating Dr. Biggs' observation it may be stated that 



OVERCROWDED COMMUNITIES 229 

the phthisis death-rate was 4*27 in 1881 and 2*40 in 1903, a 
fall of 44 per cent. ; the corresponding rates in London being 
2* 18 and r6o and its fall 26 per cent. 

Further figures comparing the conditions of housing in 
different countries are summarised by Dr. Shad well (1905, 
vol. ii. p. 198) in the following sentence : "In England the 
industrial classes live in separate houses or cottages, in Germany 
they live in barracks, and in America in larger houses which 
are shared by more than one family.' ' He adds: "We have 
nothing to compare in England to the house famine which 
prevails in Germany." 

The outcome of the available figures is to show improve- 
ment of housing associated with 

(a) decrease of phthisis (England, Scotland), 

(b) stationary or increasing phthisis (Ireland and Norway) ; 
and heavily and increasingly congested housing associated with 

(a) high and almost stationary phthisis death-rate (Paris), 

(b) great decrease of phthisis death-rate, which is still high 

(Germany, Berlin, New York). 
It is highly probable that neither the association between 
improved housing and reduced phthisis in Great Britain, nor 
that between very congested housing and high phthisis rates 
in the foreign countries quoted is accidental. In view of the 
known pathology of the disease, no circumstance could be 
more calculated to exercise a uniformly adverse influence on 
this disease than overcrowding. Clearly, however, abnormally 
high congestion of housing has been unable in most of the above 
countries to prevent immense decrease in the phthisis rate ; 
and marked improvement in housing in Ireland, which has 
brought it well above the level of Scotland as to average number 
of rooms per dwelling for the very poor, has not sufficed to 
prevent the rise of the phthisis rate. Overcrowding must 
therefore be classed with urbanisation as a factor which, though 
of proved effect on the phthisis rate, has usually been unable 
to overcome counteracting influences by which the phthisis 
rate has been diminished. 



CHAPTER XXXII 

TUBERCULOSIS IN COMMUNITIES OF VARYING 
WELL-BEING 

THE influence of well-being on the phthisis death-rate has 
never been questioned, and in the judgment of many 
authorities it is the most important factor. Thus Sir 
Hugh Beevor (1901, p. 158) says : — 

As the wages rise, phthisis rate falls ; this fall affects especially the 
young ; it is due to food supply. 

In another place (1899) he says : — 

The British public eat more and more. Agricultural returns declare 
that in the last twenty years, the yearly ration per head of the public 
had increased 10 per cent, in both bread and meat. . . . Nowadays, 
patients at Nordrach rightly hold that their extra feeding is a great means 
of cure ; nutrition is equally a means of prevention. 

Sir Douglas Powell (1904) gives expression to the same view 
in the following statement : — 

The prevention of consumption involves a much wider issue than 
the circumvention of the bacillus. . . . The abolition of the Corn Duties 
and other Free Trade legislation, and improved rates of wages, have 
done more than any notification law against the disease would have been 
likely to have effected. 

It may be assumed that, in the above extract, the action 
which in a well-regulated district would follow on notification 
is indicated. 

Well-being is, of course, a very complex condition, which 
cannot be measured completely by any single element. No 
factor, however, more deserves careful attention, and in the 
following pages its course is measured independently by the 

price of wheat, the cost of total food, the total cost of living, 

230 



COMMUNITIES OF VARYING WELL-BEING 231 

wages, the amounts of food consumed, and the amount of 
pauperism. In considering those elements which relate to food 
it must be remembered that we are dealing not with the thera- 
peutic effect of these elements on tuberculous patients on whom 
they are applied under exceptional conditions and in some excess, 
but with their prophylactic influence taken in normal quantities 
and in the circumstances of ordinary life. Much clinical experi- 
ence appears to indicate that high feeding, especially with 
proteids, has a marked beneficial effect in the treatment of 
tuberculosis ; and although, so far as I know, there is no record 
of its value apart from open-air treatment, and the latter may 
therefore possibly be partially responsible for the beneficial 
results ascribed to the former, it is likely that the high diet has 
been at least an important factor in the therapeutical effect. It 
is, of course, quite possible that food in no more than ordinary 
amounts, and especially proteid food, may exert in health a 
prophylactic influence against tuberculosis similar to the thera- 
peutic effect on the consumptive exerted by abnormally high 
amounts under open-air conditions. On existing evidence, how- 
ever, it is equally possible that a certain minimum excess is 
necessary for producing the predominant therapeutic effect 
which has been remarked ; and a similar excess may conceivably 
be necessary to the production of the fullest prophylaxis that 
can be obtained by diet. There is, so far as I know, no evidence 
to enable one to decide between these possibilities. 

In using the figures which express the extent to which the 
countries under comparison have enjoyed the several elements 
of well-being, no correction is made for the varying benefit which 
different persons and possibly different nations will have derived 
from equal amounts of commodities. The absence of such 
correction in the present inquiry is without serious importance. 
The nation in whom thrift or superior efficiency in utilising their 
means might have been supposed to have produced the decrease 
in phthisis is Germany ; and if it were in fact shown that Germans 
had such superiority over the other nations in question, then 
the bare comparison of their means with those of less thrifty 
nations would be inconclusive. In the present discussion, how- 
ever, the inclusion of France and Norway, whose figures for 
phthisis are very different from those of Germany and whose 
reputation for thrift is equally high, avoids the difficulty. 



232 



THE PREVENTION OF TUBERCULOSIS 



Price of Wheat 

In Table L. the proportional prices of wheat and the death- 
rates from phthisis in several countries are given relatively to 
the corresponding prices or rates in 1901-02, which are stated 
as 100. 

Table L 
Relative Figures for Wheat and Phthisis 





Wheat. 


Phthisis. 














in 












to 








i> 


a 

C 


c 

S 


en 


rr-l W 



c 




3 


'j-i 


1 


O 3 

J-c l-i 






P 3 


u 





'2 


C 

W 


O 







Pk 


t/J 


3 




1841-50 . 


197 


125 


116 


143 


















1851-60 . 


201 


I40 


147 


186 


229 
209 


206 
169 


162 






246 

233 


... 


(-1851-55 
\ 1856-60 


1861-70 . 


188 


137 


132 


228 


208 
200 


I70 
173 


172 
176 


83 
85 


124 
168 


219 
201 




f 1861-65 
\ 1 866-70 


1871-75 . 


20I 


i.ti 


14s 


206 


181 


152 


169 


89 


no 


207 






1876-80 . 


175 


139 


130 


164 


166 


I46 


157 


93 


III 


186 


165 




1881-85 . 


I48 


120 


"3 


140 


149 


128 


144 


97 


121 


189 


103 




1886-90 . 


116 


114 


107 


112 


134 


114 


128 


99 


121 


164 


145 




1891-95 . 


I03 


108 


103 


91 


119 


113 


120 


99 


112 


140 


121 




I 896-1 900 


I05 


IO4 


IOO 


105 


108 


IO9 


114 


99 


IO4 


119 


104 




1901-02 . 


IOO 


IOO 


IOO 


IOO 


IOO 


IOO 


IOO 


100 


IOO 


IOO 


IOO 






326 


440 


426 


328 


123 


165 


147 


215 


365 


167 


193 




Absolute price in 


I 


)eath-rates per 


I0O,0 


00 fr 


Dm 




pence per imperial 


Phtl 


lisis or Tubercu 


losis 


m 19 


01-02 






gallon in the years 




or 1901 


-03- 










taken as standard. 















In Figs. 20 to 23 the facts of Table L. are shown diagram- 
matically. By the use of proportional figures the curves of prices 
and phthisis rates are reduced to the same scale, and can be 
exactly compared. 

Fig. 20 shows the phthisis and wheat curves for the United 
Kingdom. As previously shown by Sir Hugh Beevor, there is a 
fairly close relationship in Great Britain between the phthisis 
and wheat curves. There is one important exception to this 



COMMUNITIES OF VARYING WELL-BEING 233 

statement. Prior to 1875 a great reduction of phthisis had 
occurred, without cheapening of wheat. 

In Ireland, which has shared the benefits of cheaper bread, 
there is obviously no relation between the price of wheat and 



ISO 


— r 



5 


-1 - r 


? 


1 1 

* 


Irt 


1 8' ' 


S ' % ' 8 ' I * 8 


- <r 

- 00 




7> 




3 


58 


K 




-L <0 ~ 2 — 

co •• 2 ■ 






<o 




2 


s 


co 


2 


co co cO to en 


~2~20 






^ 










— ••" — <n — 

to 


- 






«5>„ 










-210 








<&> 








- 










& 








- 










Vf 








E-200W^ 


1- 


L. 


^ 




V* 








- 






*» 


^, 


\ ' 


\ 
























-190 










V \ 








— 










^» ^ 




> 




~ 














\ 




_ 














\ 




— 180 














\ 




- 








..... 


..'..••. 




\ V 




—170 




9 


'p'hthis 






**j 






z 












•>\ 


\ \ 




_ 














*• \ v 




- 














*, \ 


\ 


-160 














*, \ 




*> 














\ 


v 


: 
















\\ 




















-130 
















v\ 


I o> 
















*• *V 


L *«• 
















*'.\ 


—140 
















'*\ 


- <». 
















t»\ 


O 
















• \ 






































— 130 w 
















* V \ 


c 
















* **.\ 


»* 
















* **.\ 


=-.20^ 


















~ ^ 
















k \*«. 


jiio a. 
















A x *• 


Z 
















* %.*• 


- 
















V- - -"^L. 


-100 
















. «*- •—O*— —Q. • ^ 


- 
















<^' 


I90 












»< 




f«' a 


- 80 




® — ■— — 




- —o*^ 


nl* 







Fig. 20. — Proportional Death-rates from Phthisis in England and Wales, 
Scotland, and Ireland, and Price of Wheat in the United Kingdom, 1841-50 
to 1901-03 
Note. — The curves in Figs. 20 to 2 6 do not show actual prices and death-rates, 

but only the proportional changes in them, 

the death-rate from phthisis. It may be stated further that the 
price of potatoes per cwt. in the ten years 1864-73 averaged 
53d. ; in the ten years 1894-1903, it averaged 4od. These are 
the means of the extreme values given in the Annual Reports of 
the Registrar-General for Ireland. 



234 



THE PREVENTION OF TUBERCULOSIS 



1 

: ? 

^-2002 


1 —j- ~t i ■ i i , , 

8 ? g ? S 9 s 

s 5 • S £ 2 » 

S 2 ■ 2 S 2 S 


— 1 — 

i 

i 


i 


m 


/ \ 






* 


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r ,d0 


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-180 


e < fi i * 








/ \ 






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_ • / 


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-170 ,' 


\ 






• 








- 


A \ 






—160 


/l * 






<-> 


/ 1 * 






~ o 


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/ 1 \ 






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/ I * 






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-MO 


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V- 


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JUL 



Fig. 21. — Proportional Death-rates from Phthisis in Paris, 1861-69 to 1901-02, 
and Price of Wheat, 1841-50 to 1901-02 



» CO 
-160 ~ 


1831-60- 






1 


s 


5 


2- 

^ </ 6 \ 


4 

8 

00 

S 


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8 

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2 








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Fig. 22. — Proportional Death-rates from Tuberculosis in Prussia, 1877-80 to 
1901-02, and Price of Wheat, 1841-50 to 1901-02 



COMMUNITIES OF VARYING WELL-BEING 



235 



Fig. 21 shows the course of the phthisis curve for Paris and the 
wheat curve for France. As already stated, it is probable that in 
Paris the phthisis rate has declined little, if at all. Even if we 
accept the official figures of declining phthisis, no correspondence 
is visible between the official figures of variation of phthisis rate 



: I 

-230 

r i2 ° 


....... t , j 

1 \ 

\ 
\ 

N 
\ 

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Fig. 23. — Proportional Death-rates from Phthisis in Massachusetts, 1851-55 
to 1901-02, and Price of Wheat, 1841-50 to 1901-02 

and price of wheat. The proportional phthisis rate increased 
from in in 1876-80 to 121 in 1881-85, while the proportional 
price of wheat fell from 173 to 146. Between 1891-95 and 
1901-02 the price of wheat has been almost stationary, and the 
recorded death-rate has fallen from 112 to 100. 

As will be seen in Fig. 22, the form in which figures are avail- 



236 THE PREVENTION OF TUBERCULOSIS 

able compels comparison between Germany and Prussia, and 
also the substitution of tuberculosis for phthisis. Between 
1876-80 and 1886-90, tuberculosis declined only from 164 in 
1876-80 and 162 in 1881-85 to 151, while wheat declined from 
130 to 107 ; while between 1886-90 and the present time, the 
decline of wheat has only been from 107 to 100, that of tubercu- 
losis from 151 in 1886-90 and 128 in 1891-95 to 100. 

In the United States, where the margin of wages is great, and 
where the price of wheat cannot be of such vital importance, 
the two curves are fairly correspondent up to 1890, but then 
diverge widely : a rise of wheat from 91 to 100 since 1891-95 
having been associated with a fall in phthisis from 139 to 100 
in 1891-95, and 119 in 1895-1900. 

The data given above for the course of phthisis and of wheat 
prices are connected by the following coefficients of correlation r 1 — 

Price of Wheat and Phthisis Death-rates 



\ 

Period of Observation. 


Coefficient of Correlation. 


England and Wales . . 1866- 1902 
Scotland .... 1868-1902 
Ireland .... 1866- 1902 
Prussia .... 1 877-1 901 
Paris 1 866- 1 902 


+ •90 
+ •87 
-•80 

+ "55 
+ •31 



Expressed in words these figures summarise the preceding 
tables and curves by showing a close co-variation between 
phthisis rates and wheat prices in England and Scotland ; 
moderate and poor co-variation in Prussia and France respec- 
tively ; and considerable inverse co- variation in Ireland. 

Total Cost of Food 

The data for a review of total cost of food in certain countries 
from 1877 are furnished in Government Blue Books (1903, 
pp. 215 and 224). " Index numbers " are employed in the 
following table based on the retail prices collected by the Labour 
Department of the Board of Trade, of bread, flour, potatoes, 
beef, mutton, bacon, butter, tea and sugar ; value being attached 

1 The sense in which this term is used is stated in the Note on p. 295. 



COMMUNITIES OF VARYING WELL-BEING 237 

to each of these articles in accordance with the annual amounts 
spent by households in the purchase of the various articles. 

Table LI 
Relative Figures for Total Cost of Food and Phthisis 





Total Cost of Food. 




Phthisis in 




Tuberculosis 
in Prussia. 


United 
Kingdom. 


Germany. 


England 1 c ., , 
and Wales.) Scotland - 

1 


Ireland. 


1877-80 . 
1881-85 . 
1886-90 . 
1891-95 . 

I 896- I 900. 

1901 . 


I3 I 
126 

102 

98 

94 
100 


112 

105 

99 
103 

99 
100 


166 
149 

134 
119 

108 

100 


157 
144 
128 
120 
114 
100 


93 
97 
99 
99 
99 
100 


165 
163 

121 

104 
100 



(The cost of food and the phthisis death-rates respectively in 1901 are stated as 100 
the other figures being given in proportion to the values for 1901) 

The same values are also shown in Figs. 24 and 25. 



170 




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Fig. 24. — Proportional Death-rates Fig. 25. — Proportional Death-rates 

from Phthisis in England and Wales, from Tuberculosis in Prussia, and 

Scotland, and Ireland, and Cost of Cost of Food in Germany, 1877-80 

Food in the United Kingdom, to 1901 
1877-80 to 1901 



238 THE PREVENTION OF TUBERCULOSIS 

It will be noted that in and since 1886-90, the price of food 
has remained almost stationary ; during the same period the 
phthisis death-rate in England has fallen in the proportion of 
134 to 100, and of Scotland in the proportion of 128 to 100. In 
Ireland a rise of phthisis has been accompanied by a marked 
decrease in the cost of food, though Ireland has experienced 
the same cheapening of food as Great Britain. 

In Germany (Fig. 25) between 1877 and 1886 the death-rate 
from tuberculosis in Prussia was stationary, while the total cost 
of food fell from 115 to 95, or from 112 to 105 in the consecutive 
periods 1877-80 and 1881-85. On the other hand, in the period 
1886-90, in which the cost of food was as low as in 1901, the 
death-rate from tuberculosis was 50 per cent, higher. 

The correlation coefficients which connect these data are 
as follows : — 

Total Cost of Food and Phthisis Death-rates 





Period of Observation. 


Coefficient of Correlation. 


England and Wales 
Scotland .... 
Ireland .... 
Germany .... 


1877-1901 
1877-1901 
1877-1901 
1877-1901 


+ •90 
+ •88 
-'49 

+ •42 



These figures show close co-variation between the phthisis 
rate and the total cost of food in England and Wales and in 
Scotland, poor co-variation in Germany, and some inverse 
co-variation in Ireland. 



Total Cost of Living 

The figures enabling the relationship between total cost of 
living and the phthisis death-rate to be stated, are derived from the 
second Fiscal Blue Book (Memoranda, etc., Second Series) . They 
refer to workmen's expenditure in London and large towns in Great 
Britain, the relative price in 1900 being in each case stated as 100. 
The proportional costs in 1881-85 and in 1900 respectively were : 
for food 133 and 100, for rent 89 and 100, for clothing 105 and 
100, for fuel and clothing together 75 and 100 ; and for all the 



COMMUNITIES OF VARYING WELL-BEING 



239 



above four chief items of workmen's expenditure 116 and ioo. 1 
The cost of living in the United Kingdom has therefore declined 
considerably, as compared with what it was in 1881. 

Fig. 26 shows the course of the phthisis death-rate, and the 
total cost of living in England and Wales. 

The total cost of living in England has been fairly uniform 
during the last fifteen years; during approximately the same 
period the phthisis death-rate has declined in the proportion 
of 134 to 100. 



155 T" 




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no £ 






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90 









Fig. 26. — Proportional Death-rates from Phthisis in England, 
and Total Cost of Living, 1881-85 to 1901-03 

There are independent reasons for believing that in Ireland 
the prices of total food, clothing, fuel, and rent have varied in 
the same directions and approximately to the same extent as 
in Great Britain ; and on this assumption the coefficient of 
correlation has been calculated for Ireland as well as for England 
and Scotland. 

1 The proportional weights" adopted in giving the data in Fig. 26 have been : 
food, 7 ; rent, 2 ; clothing, 2 ; fuel and light, 1, of a total expenditure on these 
items of 12. 



240 



THE PREVENTION OF TUBERCULOSIS 



Thus when to cost of food is added that of clothing and fuel 
and rent, which in importance are second only to the cost of 
food, the direct co-variation with the phthisis rate becomes less 
marked in Great Britain and some inverse co- variation con- 
tinues to be shown in the experience of Ireland. 

Total Cost of Living and Phthisis Death-rates 





Period of Observation. 


Coefficient of Correlation. 


England and Wales 
Scotland .... 
Ireland .... 


I 880- 1 903 
1 880- 1 902 
1 880- 1 903 


+ 76 
+ 76 
-•24 



Wages 

It may be suggested that the lack of correspondence between 
cost of living and death-rate from phthisis may be due to the 
disturbing effect of changes in wages. Unfortunately, exact 
comparison of wages can only be made from official data for 
workmen engaged in skilled trades and for agricultural labourers. 
It is probable, however, that these wages give some clue to the 
corresponding wages of other workmen. 

Table LIT compares the recent experience of different coun- 
tries. 

Table LII 

Comparison of Rates of Wages in Skilled Trades 



Number of quotations of wages on which the following 
results are based ....... 



Mean weekly wages for/i. Capital cities . 

15 skilled trades \2. Other cities and towns 

Percentage comparison / 1 . Capital cities . 

(United Kingdom = 100) \2. Other cities and towns 



V 




c 
a 


c 

s 


is 




i*H 







PC/3 


470 


248 


184 


141 


s. d. 


s. d. 


s. d. 


s. d. 


42 


36 


24 


75 


36 


22 10 


22 6 


69 4 


100 


S6 


57 


179 


100 


63 


63 


193 



British money wages are the highest in Europe, and the 
margin over the cost of living is probably the greatest in Europe. 



COMMUNITIES OF VARYING WELL-BEING 241 



The Board of Trade's Report gives the following comparison 
of average family incomes : — 



United Kingdom. 
100 



France. 
83 



Germany. 
69 



United States. 
123 



The preceding official data are confirmed by facts inde- 
pendently collected by Dr. Shadwell (1905, vol. ii. pp. 81 and 
91). He gives the following ratios for wages of unskilled 
labourers in the three countries : — 



England. 
100 



Germany. 
79 



United States. 
143 



and he believes that these figures more nearly represent the 
actual state of matters than those in Table LIL, which give the 
ratios for skilled workmen as 100, 57, and 179 in the capitals, 
and 100, 63, and 193 in other towns. 

The only comparison of wages practicable between different 
parts of the United Kingdom is for agricultural labourers. The 
data for this comparison are derived from an important report 
by Mr. Wilson Fox, C.B. (Cd. 2376, p. 5). He gives the following 
table :— 

Table LIII 

Average Earnings per Week (including the Value of all Allowances in Kind) 
of Able-bodied Male Adult Ordinary Agricultural Labourers 









Percentage Increase 




1902. 


1898. 


between 
1898 and 1902. 




s. d. 


s. d. 




England 


17 5 


16 9 


4-0 


Wales .... 


17 7 


16 6 


6-6 


Scotland 


19 5 


18 2 


6-9 


Ireland. 


10 9 


10 2 


57 



On p. 5 of the same report Mr. Fox remarks : " There is no 
doubt that the position of a farm labourer in Ireland is not so 
good as in other parts of the United Kingdom, but it may be 
added that he gets his house and fuel cheaper, and frequently 
has the opportunity of renting land on which he grows potatoes 
and keeps pigs, goats, and poultry." 

This report enables a comparison to be made for agricultural 
labourers over a long series of years in the three parts of the 
16 



242 



THE PREVENTION OF TUBERCULOSIS 



United Kingdom. The following table illustrates the course of 
wages on certain sample farms between 1850 and 1903. The 
rates of wages are expressed in percentages, the year 1900 
being taken to represent 100 : — 

Table LIV 





1850. 1 i860. 


1870. 


1880. 


1890. 


1900. 


1903. 


England and Wales (69 farms) 
Scotland (6 farms) 
Ireland (10 farms) 


64 j 76 
50 60 
56 6 3 


82 
7i 
7i 


9i 
85 
81 


90 

9i 
90 


100 
100 
100 


IOI 

103 

IOI 



Mr. Wilson Fox, in answer to an inquiry, kindly writes 
me the following statement (May 16, 1906) : "As stated on 
p. 220 of the Report " (On the Wages, etc., of Agricultural Labourers 
in the United Kingdom), " the employers who furnished these 
records were asked if the allowances in kind, given in addition 
to cash wages, had varied during the period of years for which 
wages were quoted, and you will see from the notes appended 
to the various records that on the whole there was very little 
variation, the tendency being to increase the extras as well as 
the rates of wages. It seems safe to assume, therefore, that 
there has been no diminution in the social well-being of farm 
labourers in Ireland, and that the steady rise in wages shown 
on p. 137 is not overstated." 

Table LV 

Ratio of Average Rates of Wages in Different Countries {exclusive in all 
Cases of Agriculture) (Cd. 1761,/. 275). Wages in 1900=100 



Years. 


United 
Kingdom. 


France. 


Germany. 


United 
States. 


Principal 

Groups 

of Trades. 


Mean of 
Skilled Trades. 


Groups of 

Principal Trades 

under Imperial 

Insurance Scheme. 


Average 

of all 
Trades. 


1881-85 
1886-90 
1891-95 
1896-99 
1900 


83-4 
84-6 

89-4 
917 

IOO'O 


86-9 
96-0 (1896) 

IOO'O 


80-9 

84-9 

927 

ioco 


90*5 
93 '3 
95-8 
96*0 

IOO'O 



COMMUNITIES OF VARYING WELL-BEING 243 

Comparing the past with the present, there has been great 
increase of wages all round (Tables LIII. and LV.). 

The greatest increase has been in Germany, the least in the 
United States. The above ratios indicate the course of wages 
in each country, not the absolute amounts. Germany, which 
shows the greatest increase of wages, still pays its workmen a 
lower average wage than that in other countries. Unfortunately, 
the comparison for Germany does not extend back beyond 1886. 
Between 1886-90 and 1891-95 the death-rate from tuberculosis 
fell 15 per cent., while wages rose 5 per cent. 

In Norway between 1885 and 1900, wages have increased 
in different industries from 24 to 53 per cent. Its phthisis 
death-rate meanwhile has not decreased. 

Thus in Germany and in Ireland wages lower than the 
British are associated with a higher phthisis rate, while in the 
United States much higher wages are associated with a much 
higher phthisis rate. In Great Britain and the United States 
rise of wages has accompanied decrease of phthisis ; in France 
no such correspondence has appeared ; and in Ireland and 
Norway considerable increase of wages has been associated 
with some increase of, or with a stationary death-rate from, 
phthisis. 

Amounts of Food Consumed 
Without entering into the figures which are given in detail 
elsewhere (1906, p. 343), it may be said that no uniform cor- 
respondence is to be found between the figures of food con- 
sumption per head of population and those of phthisis. England 
with the lowest phthisis rate has by far the highest consumption 
of meat, though not of other foods ; and Belgium, with sub- 
stantially the same phthisis rate and the same decrease as 
England in the period under examination, consumes less meat 
than any country except Ireland, and less than half the amount 
consumed in England. France, with a large and steadily 
increasing consumption of meat and of other foods, has, judging 
by Paris, the largest phthisis death-rate, with no certain evidence 
of improvement. 

Pauperism 
Hitherto we have dealt with the experience of various 



244 THE PREVENTION OF TUBERCULOSIS 

countries in regard to the positive elements of well-being. It 
remains to see to what extent these results can be checked by 
figures expressing the absence of well-being. Owing to the 
different methods of relieving poverty, we can only examine 
the figures relating to poverty in the countries of the United 
Kingdom, using for this purpose the poor-law returns. Before 
doing so, it is desirable to realise what figures of pauperism 
really indicate. Pauperism is officially-relieved poverty ; and 
poverty itself, while most often due to absence of means, may 
also arise from the unskilful, careless, or mischievous use of 
means, from thriftlessness, sloth, or intemperance. The con- 
ditions which accompany poverty, such as protracted exposure 
to infection, insufficient nutrition, and ignorance, work in a 
vicious circle with the conditions that cause it, till it is difficult 
or impossible to distinguish those elements of poverty repre- 
senting destitution, and relievable by the provision of ampler 
means, from those which are of an origin independent of 
material supplies, and which would persist even in a community 
free from economic deficiencies. Poverty therefore is itself 
a most complex phenomenon, not to be remedied by any single 
set of measures ; and figures of actual poverty, even if they 
could be had, would not in themselves suffice to estimate the 
causes from which the poverty arose nor the steps which would 
be necessary to remove them. In fact, however, we have not 
figures of poverty, but only of pauperism, i.e. of State-relieved 
poverty. The amount of pauperism depends obviously, not 
alone on the extent of poverty, but also on the test or standard 
by which the scale of relief is determined ; and a given amount 
of poverty will beyond doubt yield very different figures of 
pauperism at various epochs and in various districts according 
to the scale of relief which happens to be applied. These con- 
siderations need to be remembered when an attempt is made 
to bring the complex phenomena of pauperism into relation 
with experience as to phthisis. It will be seen, shortly, that 
in the United Kingdom during the period under observation 
there has been a correspondence between the variations of 
phthisis and those of pauperism so marked as to justify the use 
of the figures of total pauperism as approximate indexes of the 
total amounts of phthisis, when the actual phthisis figures 
cannot be had. This does not mean that the variations 



COMMUNITIES OF VARYING WELL-BEING 245 

in pauperism explain the variations in the death-rate from 
phthisis. Within the bundle of phenomena which constitute 
pauperism such an explanation may be found ; but until we 
ascertain which individual element or elements of the bundle 
contain the explanation, to explain the figures of phthisis by 



















ENGLAND 


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Fig. 27. — England and Wales. Showing the relative Changes in the Number 
of Indoor and of Total Paupers and in the Deaths from Phthisis per 100,000 
of Population from 1857-60 to 1901-03 

those of pauperism is for any practical purpose to explain a 
complex ignotum by a yet more complex ignotius. 

In considering the experience of Great Britain it must be 



246 



THE PREVENTION OF TUBERCULOSIS 



remembered that about 1870 there was a vigorous and largely 
successful movement for insisting on the " house-test " for relief ; 
and the sudden drop of total pauperism about this date and 
during the subsequent decade arose largely from this cause. 



























LONDON 
























































































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Fig. 28. — London. Showing the relative Changes in the Number of Indoor 
and of Total Paupers and in the Deaths from Phthisis per 100,000 of Popula- 
tion from 1857-60 to 1901-03 



COMMUNITIES OF VARYING WELL-BEING 247 

Simultaneously there was great improvement in the workhouse 
accommodation, particularly in its infirmary department. The 
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Fig. 29.— Scotland. Showing the relative Changes in the Number of Indoor 
and of Total Paupers and in the Deaths from Phthisis per 100,000 of Popula- 
tion from 1857-60 to 1901-03 

Ireland, as shown in Fig. 30, a rigid system in which indoor, i.e. 
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Fig. 30.— Ireland. Showing the relative Changes in the Number of Indoor 
and of Total Paupers and in the Deaths from Phthisis per 1 00,000 of Popula- 
tion from 1857-60 to 1901-03 



COMMUNITIES OF VARYING WELL-BEING 



249 



of former times, this has been associated with a great increase of 
official pauperism ; and apart from the facts which independently 
make it improbable that this increase of official pauperism was 
due to increase of privation in this very poor country, such a 
sweeping change in administration must have produced an 
increased number of paupers for a given amount of destitution. 

Unfortunately there are no figures of pauperism for foreign 
countries suitable for comparison with our own ; and it is there- 
fore desirable to examine those of the United Kingdom with 
some minuteness. The course of pauperism in each country of 
the United Kingdom and in London is shown in Figs. 27 to 30. 
In order to compare the curve of total pauperism in each instance 
with the corresponding curve of the phthisis death-rate, the 
curves of total pauperism and of phthisis have been reduced to 
the same scale by stating the experience for the earliest period 
in each instance as 100, and the subsequent rates in their pro- 
portion to this. 

It will be seen that if allowance be made for the reduction in 
the relief figures introduced about 1870 by the more rigid insist- 
ence on the " house-test," there is a correspondence between the 
curves of phthisis and of total pauperism. The following table 
shows the corresponding percentage declines of each for the 
whole period and for its constituent quinquennia : — 

Table LVI. — England and Wales 
Percentage Decli?ies of Rates of Phthisis and of Pauperism 



Phthisis Death-rate. 
Total Pauperism -rate 






O 

o 

vb O ij 

^ o 
~ 2*1 



00 00 



49-8 
S2'3 



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*r» co 

co 00 



9 '4 
177 



22*1 



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IO'2 

37 



io"3 
4-2 



io*9 
9*5 



t * 

M 00 



9-6 

5 '4 



To! 

5 a 



6-8 
6-o 



The total decreases for the entire period — 49*8 per cent, for 
phthisis and 52*3 per cent, for pauperism — are surprisingly 
close. Individual quinquennia show some discrepancies ; but 
as phthisis has a long course and may have a still longer period 
of latency, and as any administrative influence is likely to operate 



250 THE PREVENTION OF TUBERCULOSIS 

slowly, a close quantitative relation between the figures for short 
periods cannot be expected. 

The correspondence in London and Scotland when allowance 
has been made for changes in administration, though not so close 
as in England and Wales, is nevertheless close. 

In Ireland, if we make the necessary allowance for the great 
increase of outdoor relief due to administrative causes shown 
in Fig. 30, and compare the subsequent curve of pauperism with 
that of phthisis, a close correspondence is seen. It would be 
unsafe to assume on historical grounds alone that the lack of exact 
parallelism between the earlier parts of the curves of phthisis 
and pauperism is due merely or mainly to administrative change. 
There is, however, independent evidence of the fact. It has 
already been shown (p. 241) that the economic condition of Ireland 
has not become worse, and that so far as can be measured by the 
tests already given it has improved. Agricultural labourers in 
1 88 1 formed 46*0 and in 1901 44*3 per cent, of the total male 
population of Ireland over 10 years of age ; and between 1870 
and 1900 the wages of these labourers had increased 42 per cent. 
Food has become cheaper, rents are low, overcrowding has 
declined, and is less marked than in Scotland (p. 227). It is 
clear that poverty has been growing less in Ireland during the 
period of observation, and that the increase of pauperism has 
therefore been due to altered administration and not to increase 
of destitution. 

The figures of pauperism and of phthisis for the entire period 
are connected by the following correlation coefficients : — 

Correlation between Total Pauperism and Phthisis 





Period. 


Coefficient of Correlation. 


England and Wales 
Scotland .... 
Ireland .... 


1 866- 1 903 
1 868- 1 902 
1 866- 1 902 


+ •89 

+ •90 
+ •83 



These figures summarise a close co-variation in each of these 
countries between phthisis death-rate and total pauperism. 
This result is what would be expected from the pathology of 
the disease. However minutely pauperism is analysed, each 



COMMUNITIES OF VARYING WELL-BEING 251 

element which is disclosed is such as would favour an increased 
phthisis rate. In each of these countries, therefore, the figures 
of pauperism confirm the a priori expectation that pauperism 
contains enough phthisiogenetic influences to make its figures 
vary closely with the figures of phthisis. 



CHAPTER XXXIII 

TUBERCULOSIS IN COMMUNITIES OF VARYING SANITARY 
EDUCATION AND SANATORIUM PROVISION 



KOCH teaches on a priori grounds that direct infection has 
a preponderating influence on the prevalence of phthisis ; 
and the facts here reviewed will be found to lead by another 
road to the same conclusion. In a passage quoted by Dr. 
Bulstrode (1903, ii. p. 208), Koch says : " The fact that tubercu- 
losis has considerably diminished in almost all civilised States 
of late is attributable to the circumstances that knowledge of the 
contagious character of tuberculosis has been more and more 
widely disseminated, and that caution in intercourse with con- 
sumptives has increased more and more in consequence." 

This statement, so far as I am aware, has not been supported 
by evidence, and it is by no means a consequence of Koch's 
discovery that tuberculosis is infectious. Before such a state- 
ment can be accepted, it must be shown, not only that caution 
in intercourse with consumptives has increased, but also that 
the increase of this caution occurred at a period and to an extent 
warranting the inference. Prior to 1884 when Koch's discovery 
of the tubercle bacillus was first fully set out, suspicion of in- 
fectivity had no notable influence on medical or public action. 
Had Koch's contention on this point been correct, the chief 

Table LVII 



Percentage Decline in Phthisis Death-rate 






1 
00 


O *o 

2- 1 

tN. 00 

00 1 00 


00 

00 


©n 

1 

o\ 

00 


8 

ON 

T 

ON 

00 


* 

1 


England and Wales . 
Scotland .... 


9*4 
3-5 


8*1 I0'2 

7-2 : 8-o 


ro-3 

io # 9 


10-9 
6-3 


9-6 

4'5 


6-8 
13T (1901-02) 



VARYING SANITARY PROVISIONS 



253 



reduction of phthisis should have occurred since 1884. In 
Germany this has been so : in Great Britain it is otherwise. 

Table LVII. gives the quinquennial percentage decline of the 
phthisis rate before and since 1885 in England and Wales and in 
Scotland (the last period is two years). 

The rate of decline was substantially as great before as 
since the infectivity of phthisis became generally known to the 
medical profession. In recent years the rate of decline has 
diminished. In Scotland the rate of decline has been more 
irregular. 

The figures of other countries are interesting in the same 

connection. 

Table LVIII 

Percentage Decline of the Death-rate from Phthisis or Tuberculosis 

between 



i 1881-85 

j and 
1886-90. 

i 


1886-90 

and 
1891-95. 


1891-95 

and 

1 896- 1 900. 


1 896- 1 900 

and 

1901-02 or 

1903 or 1904. 


Switzerland ... 1 2 
Prussia . 7 
Paris . . . . . \ 


8 

15 

5 


3 
16 

7 


7 
3 



In several of these countries a slackening of the rate of decline 
of the phthisis death-rate is noticeable in recent years. It will 
not be contended by the anti-contagionist that education and 
consequent precautions have caused this diminution in the rate 
of decline. Neither, on the other hand, is it possible to show 
that the extremely limited action taken on directly preventive 
lines has so far impressed itself on national statistics. As the 
matter stands, there is no evidence of a causal connection suffici- 
ently large to be traceable between the decline of the phthisis 
death-rates and the progress of education in hygienic matters. 

Similarly, no practical result can have followed from the 
amount of voluntary or compulsory notification of phthisis 
which has occurred in England. This is by no means because 
notification has no useful part in the prevention of tuberculosis, 
but because it is useless without the administrative mechanism 
which is necessary for turning it to account for the welfare both 
of the community and of the patient. No valid conclusions as 



254 



THE PREVENTION OF TUBERCULOSIS 



to the utility of notification could be drawn from the experience 
of towns which are not so equipped, or which have been so only 
for a short term of years ; and in view of the important part 
which notification should play in a properly arranged mechanism 
for the control of tuberculosis, the error of attempting to draw 
such conclusions is more than an academical fault, and is much to 
be deprecated. 

Nor conversely can it be imagined that similar educative 
influences have been entirely absent from Ireland and Norway, 
in which an increase, or from France in which probably no decline, 
of phthisis has occurred. The action taken in consequence of 
knowledge of the infectiousness of phthisis has doubtless varied 
greatly in different countries and in different parts of the same 
country. In Germany alone can treatment in special sanatoria 
have any claim to the decline which has occurred, as the use of 
these elsewhere has until a few years ago been on a very small 
scale compared with the total amount of disease. Sanatorium 
treatment, furthermore, has, with the same exception, been 
employed chiefly for well-to-do patients who from the public 

Table LIX. — Sanatoria in Germany 











Public. 


Private. 


Prussia. 


Year Opened. 






Tuberculosis 




Number of Beds. 


Number of Beds. 


Death-rate 
per 1000. 


1854 . . 




300 




1873 












120 




1875 












80 




1876 












114 




1881 












100 


307 


1885 












12 


311 


1887 












100 


290 


1889 












205 


279 


1892 








94 




248 


1893 








103 




248 


1894 










275 


237 


1895 








196 




231 


1896 








195 




217 


1897 








504 




214 


1898 








958 


135 


197 


1899 








590 


119 


202 


1900 








817 




205 


1 901 








794 


66 


196 


1902 .... 


811 







VARYING SANITARY PROVISIONS 255 

health standpoint need it least . Even in Germany the sanatorium 
treatment of phthisis was, as will be seen in Table LIX., 
on a very small scale until after 1892, when the first popular 
sanatoria were opened (Santoliquido, 1903) ; and these institu- 
tions cannot have played more than an insignificant part in 
the great decline of the death-rate from tuberculosis which took 
place between 1886-89 ano ^ I 890~93. Of the great value of 
sanatoria in the treatment of phthisis there can be no doubt, 
nor of their even greater educational value ; but their main 
utility lies in the future. 



CHAPTER XXXIV 

THE GENERAL RELATIONSHIP OF INSTITUTIONAL 
SEGREGATION TO TUBERCULOSIS AND CERTAIN 
OTHER INFECTIOUS DISEASES 

WE have seen that both general improvement in communal 
health and each individual measure which tends to 
produce it must work powerfully towards the reduction 
of tuberculosis, but that nevertheless the disease has varied in 
communal experience in a quite irregular relation to each and 
all of these important influences. In the words of Sir William 
Broadbent (1905, p. 118) : — 

Supposing that the best possible sanitation, the best possible food, and 
the best possible conditions of life, were an adequate protection against 
phthisis, we ought to have no such thing amongst the better classes. 
But it does get there somehow. 

In Norway, Ireland, France, and Austria, the same influences 
of improved general health, well-being, and sanitary education 
have operated as in Great Britain, Germany, Belgium, and the 
United States, side by side with widely different variations in 
the respective death-rates in these countries from tuberculosis. 
Similar discrepancies have been seen when other elements of 
sanitary environment have been compared with the variations 
of the disease. 

It will next be seen that the only constant correspondence 
between the variations in the prevalence of tuberculosis and in 
any element of sanitary environment consists in the relation to 
tuberculosis of the institutional segregation of patients. 

Whether for good or harm, the segregation of infective 
patients is likely to influence the spread of tuberculosis. The 
operation of this measure on tuberculosis follows obviously 
from the infectious character of the disease ; and it will be 

convenient here to recall what has been described on this subject 

256 



RELATIONS TO INSTITUTIONAL SEGREGATION 257 

in Part I. The vast majority of pathologists and hygienists 
are agreed that the chief source of infection in human tuber- 
culosis is the tuberculous human patient. Whether he is more 
infectious at early or at later stages has not been ascertained 
definitely ; but in cases of pulmonary tuberculosis it may be 
assumed safely that the infectivity varies with the amount of 
the sputum. There is no evidence that with advancing disease 
the patient becomes less able to disseminate infection ; on the 
contrary, in advanced cases the patient is less able to control 
its hygienic disposal. The period of latency of the disease 
appears to be very variable. Small doses of infection lead to 
immediate limitation of the disease, which may be followed after 
a long interval by invasion of other parts of the body from the 
localised tuberculous lesion. Pending such an explosion the lesion 
may be utterly unrecognisable by clinical symptoms. Experi- 
mentally, statistically, and clinically, it has been shown that 
" the disease as a rule advances not by a continuous progress, 
but by a series of successive invasions separated by variable 
intervals. After each invasion, or, as it has been termed, 
eruption of tuberculosis, there is a temporary self -limitation of 
the disease." The earlier invasions may date years back. 
During the patient's life they may be wholly unsuspected or 
evidenced only by the recollections of an earlier attack of pleurisy 
or haemoptysis, often many years prior to the diagnosed tuber- 
culosis ; and this earlier attack may itself be a secondary result 
of a still earlier disease in the bronchial or mesenteric glands. 

The infection of tuberculosis, in short, is often acquired with- 
out at the time causing any recognisable illness in the infected 
person. Most acute infections, as for instance that of scarlet 
fever, are either followed by a recognised attack of the disease 
within a few days, or the person escapes entirely. The infection 
of tuberculosis, while it appears to require a much larger dose 
or more protracted exposure before evident disease is produced, 
may, on the contrary, be saved up within the infected person 
for years, and be discovered only after lapse of time and change 
of circumstances have destroyed the chance of tracing its origin. 
The infection which may be spread by an individual patient, 
or even by a whole group of patients within the practice of a 
single physician, may thus be wholly or partially concealed, 
and give rise to a mistaken estimate of the infectivity of the 
17 



258 THE PREVENTION OF TUBERCULOSIS 

disease. No better evidence of this fact can be needed than 
the historical circumstance that for many centuries the existence 
of any infectivity at all escaped recognition, and indeed did not 
become accepted doctrine until it had been demonstrated by 
actual experiment on animals. But though commonly unknown 
by the patient and his family, and commonly unrecognisable 
even to the physician in charge of the infecting case, the com- 
municated infection remains within the body of the community 
as a standing danger. In the proportion in which such latent 
infections come ultimately to fruition as disease they are bound 
to appear in the actual experience of the community ; and it 
is necessary to turn to that experience for sure and unspeculative 
guidance in seeking to master the disease. 

It is evident that institutional segregation is different 
qualitatively from domestic segregation. The average home, 
both in its bedrooms and its living rooms, has far less special 
accommodation per head, and a far lower standard of pre- 
cautions against infection, than the average institution. Two 
persons and often three may occupy the same bed in the 
home; never more than one in the hospital. In institutions, 
and by reason of the abundance of gratuitous labour, notably in 
workhouse infirmaries in this country, the average standard of 
cleanliness is far higher than in most homes. Spittoons and 
spit-cups are provided and cleaned, washing of body and bed- 
linen is not spared, and the floors, etc., of each room are kept 
scrubbed and kept free from dust. In private houses, the 
crowding of furniture, the presence of mats and carpets, and 
the exigencies of life in the families of the poor, do not encourage 
and sometimes do not even permit of such frequent and per- 
sistent cleanings. It follows that the inmates of the home, 
including children of the most susceptible age, must be far 
more exposed to infection when the patient remains at home 
than are the inmates of an institution to which he is transferred. 

It remains to see how far the institutional segregation of 
infective patients which is secured in institutions in general 
has in actual fact served to control the spread of the disease. 
Before turning to the facts of communal experience by which 
these theoretical anticipations are confirmed, a hypothetical case 
suggested by Sir Hugh Beevor (1905) may serve to illustrate the 
order of magnitude of the influence under consideration. 



RELATIONS TO INSTITUTIONAL SEGREGATION 259 

Let it be supposed that no influence was operating to 
control the prevalence of consumption except that of institutional 
segregation. In Brighton 20 per cent, of the total consumptives 
are segregated in its workhouse infirmary, and for the purpose 
of this calculation this proportion may be supposed to hold 
good for England and Wales. The examples given on p. 274 
suggest that one-third of a year may be taken as the average stay 
of each patient, and Sir Hugh Beevor in common with others 
apparently would put the total period of infectivity at three years. 
If these figures hold good for England and Wales, it follows that 
just over 2 per cent, of the total infection of phthisis is prevented 
from spreading outside institutions. On this supposition, and 
if personal infection were the sole means of communicating the 
disease, the death-rate from phthisis ought to have declined 
in each year to the extent of the segregation, namely, 2 per cent. 
A reference to Table LVII. shows that from 1871 to the present 
time the decline year by year in the death-rate from phthisis 
has been usually under 2 per cent. The calculation, although 
interesting and suggestive, does not, of course, give any accurate 
measure of the institutional segregation of phthisis, nor even of 
its practical effect. Other influences besides segregation have 
been operating, some to restrain and some to promote the 
spread of the disease ; the extent of segregation may have been 
more or less than has been assumed ; its quality must un- 
doubtedly have varied from place to place ; and when figures 
such as those of a single town are considered, the order of 
magnitude of which is vastly less than those of the whole country, 
the result is influenced by migration as previously indicated. 
The calculation shows, however, that the influence of segregation 
in institutions, as practised in England, has an order of magnitude 
fully sufficing to explain by itself the decrease of phthisis which 
has been secured, and it illustrates aptly the far-reaching result 
which may be hoped for from the withdrawal of infection from the 
community even to an extent which on careless inspection may 
appear to be too slight to have exercised an appreciable effect. 

A brief statement of the history of typhus fever in Ireland 
and of leprosy in Norway throws some side-light on the influence 
of segregation in two other infectious diseases, one very acute 
and the other very chronic in its course. These diseases, like 
tuberculosis, have in the past been associated very closely with 




Fig. 3 1.— Comparison of the Changes in the Death-rates from Typhus and from 

percentage deviations from the average 



RELATIONS TO INSTITUTIONAL SEGREGATION 261 



PHTHISSS. 




Phthisis in Ireland and in England and Wales, as shown in each country by 
death-rate for the entire period. 



262 THE PREVENTION OF TUBERCULOSIS 

unwholesome conditions of life, and the history of their decline 
is instructive in its bearing on the problem of tuberculosis. 

Typhus in Ireland. — The history of typhus in Ireland is 
closely wrapped up with that of want and famine. Famine 
has caused rapid spread of typhus, in the main because it has 
increased enormously the wanderings of vagrants from one part 
of Ireland to another, and to other countries. The disease 
began to abate when fever hospitals were generally provided, 
and when the families of infectious patients became relatively 
immobilised by the provision of poor-law relief. Fig. 31 
displays the course of the death-rate from typhus and from 
phthisis in Ireland and in England since 1868. It will be seen 
that typhus has declined greatly in both countries ; in England 
it has approached extinction, and in Ireland it is following, 
though more slowly, in the same direction. 

Phthisis, on the other hand, though it has declined greatly 
in England, in Ireland has not only not declined, but has even 
shown some increase. In the light of these national experiences, 
it can scarcely be maintained that diminution of domestic over- 
crowding and improvement in housing, — which have been 
regarded as the predominant factors in the decline of both diseases, 
— can have produced for typhus a diminution in both countries, 
and for phthisis a diminution in one country and none in the 
other. The detailed facts given in Chapters XXX.-XXXII. 
show that in both countries there has been marked diminution 
of overcrowding, improvement in housing, and cheapening of the 
means of living along with increase of wages. These facts 
justify the inference that some differentia between the two 
countries exists for phthisis, which does not exist for typhus 
fever ; and the history of the two diseases in Ireland and in 
England fits in with this inference. In Ireland the chief mass of 
sickness, especially of phthisis, is treated domestically (see 
pp. 280 and 282 for details, and especially p. 284 for the facts 
bearing on the quality of institutional treatment in Ireland). 
This is not the case in regard to typhus fever. By means of 
fever hospitals and by preventing the wanderings of the poor, 
the dissemination of typhus has been greatly diminished; and 
Ireland has secured a decrease of typhus, as has also England 
by similar means. In both countries, doubtless, diminished 
domestic overcrowding and clearing of crowded courts and 



RELATIONS TO INSTITUTIONAL SEGREGATION 263 

other dwellings has helped in producing the result ; but the 
detailed experience of Ireland x clearly indicates that the im- 
mobilisation of infection has been the chief operative factor. 

Leprosy in Norway. — The history of leprosy forms an 
interesting chapter in the history of disease, more particularly 
so in its bearing on the history of tuberculosis. Both diseases 
are caused by bacilli producing granulomatous tissue changes ; 
in both there may be a long period of latency before the signs of 
disease appear ; and in both the disease is commonly protracted 
and intermittent in its progress. Both likewise are diseases to 
which the designation " sub-infectious " has been applied, 
though the name is misleading, and is no more applicable to 
them than to syphilis, in which similar phenomena of long latency 
of symptoms, and of protracted and intermittent course are 
seen, and in which, furthermore, hereditary predisposition is not 
known to occur. The further interest attaches to leprosy, that 
acute differences of opinion exist as to the cause of its partial or 
complete disappearance from England and some other countries, 
which recall the similar differences of opinion as to the cause of the 
great decline of tuberculosis in certain countries during the last 
forty years. 

The history of the disappearance of leprosy has been associated 
with the existence on a very considerable scale of leper asylums 
in the countries from which the disease has disappeared. In 
mediaeval England such lazar houses were numerous, and 
although complete segregation of all patients was never secured, 
there doubtless was segregation of a large percentage of the total 
cases during a considerable part of their illness. Here again the 
resemblance to what has been happening in the case of tuber- 
culosis, as will be shown shortly, is striking. There is no intrinsic 
difficulty in accepting it as fact that in leprosy, — in which, as in 
tuberculosis, infection occurs chiefly after protracted infection 
of an intimate character, — the isolation of lepers must, if 
carried out to a sufficient extent, have served to bring about a 
steady decline and eventual disappearance of this disease. This 
conclusion is confirmed by the experience of Norway, which 
amounts almost to a check experiment. In this country until 

1 Further details of the history of typhus in Ireland are given in an address by 
the author on " Poverty and Disease as illustrated by the Course of Typhus Fever 
and Phthisis in Ireland " (Journal of the Royal Society of Medicine, Dec. 1908). 



264 



THE PREVENTION OF TUBERCULOSIS 



far on in the nineteenth century there were leper asylums. As 
Dr. Vandyke Carter put it, there never prevailed in Norway " the 
same systematic and rigorous opposition to the leprous pest as 
was aroused in Europe generally." During the first half of the 
nineteenth century leprosy was increasing in Norway. Thus the 
yearly average number of fresh cases of leprosy ascertained and 



Norway - Leprosy 




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1 



Fig. 32.— Norway. Number of Total Lepers and of Lepers in Asylums per 
100,000 of population, 1856-60 to 1901-05 

registered in 1840-45 was 43, in 1846-50 it was 124, in 1851-55 
it was 219, in 1855-60 it was 233, and in 1861-65 it was 225. 
Even allowing for the possibility of increasing accuracy of 
registration, it is clear that there was no decline in this disease. 
In 1856 notification of cases by medical men became com- 
pulsory, and for all years onwards the official statistics state 
the total number of known cases of the disease and the number 



RELATIONS TO INSTITUTIONAL SEGREGATION 265 

segregated in asylums. The diagram on preceding page shows 
these facts for quinquennial periods. It will be observed that 
the steady pursuit of an intelligent policy of segregation of leprous 
patients, — almost entirely without compulsion, 1 — has been asso- 
ciated with a steady and continuous decline of the prevalence of 
leprosy. At no time has there been total segregation of all known 
cases. Of the total cases about 16 per cent, were segregated in 
1856-60, 27 per cent, in the next period, 30 per cent, in 1871-75, 
32 per cent, in 1876-80, then 36 and 46 per cent, in the two next 
periods, the proportion of segregation in the three most recent 
quinquennial periods being about 52 per cent, of the total known 
cases. In the light of our knowledge that leprosy is a com- 
municable disease, of its history in other countries, and of the 
close correlation between the phenomena of segregation and 
diminution of disease (which is expressed by a coefficient of 
correlation of '95 for the entire period), it is reasonable to give 
the chief place to segregation as the means by which the diminu- 
tion of disease has been secured. 

1 Some indirect compulsion has been exercised by refusing non-institutional 
relief. 



CHAPTER XXXV 

TUBERCULOSIS IN COMMUNITIES WITH VARYING 
AMOUNTS OF INSTITUTIONAL SEGREGATION 

THE exact measure of institutional segregation of phthisis is 
the ratio stating how many of the total days of sickness 
(number of patients and number of days of sickness) is 
passed in institutions. This ratio and the equivalents for it 
which have to be used in practice may for convenience be called 
the segregation ratio. The need for equivalents for the ratio as 
stated above arises from the fact that we are dealing with actual 
recorded experience, and the statistical material has to be taken 
from the records as they happen to exist. These records appear 
in very various forms in different communities. In existing 
circumstances of notification they can never state directly the 
number of days of tuberculous sickness, and only exceptionally for 
comparatively small communities can they state the number of 
such days passed in institutions. It becomes necessary therefore 
to select other figures which vary approximately with the total 
days of tuberculous sickness and the total days of tuberculous 
sickness passed in institutions. Such figures may represent 
them respectively on quite different scales ; but so long as com- 
parison is made only between segregation ratios, in which the 
substituted figures represent similar phenomena, the particular 
scale on which they represent the phenomenon of institutional 
segregation is of no consequence. From the records in various 
countries we can learn either how many of the total deaths 
from all causes and from tuberculosis or from phthisis occur 
in institutions, or how many of the total paupers are indoor 
paupers, or how many cases of tuberculosis or phthisis are 
treated in institutions, and how many deaths from these diseases 
occur in the whole community for each case treated in an 
institution. 

From what has been said, it will be seen that these figures 

266 



AMOUNTS OF INSTITUTIONAL SEGREGATION 267 

measure with approximate accuracy the ratio which states how 
many of total days of tuberculous sickness are passed in institu- 
tions. Thus, for instance, in the absence of change of type of 
disease and of material change in efficiency of treatment, the 
number of deaths from tuberculosis is an approximate measure of 
the number of cases, and so is the number of deaths from all 
causes for short periods during which the relation of the death- 
rate for phthisis to that for all causes does not vary markedly. 

The fraction of total deaths in the population occurring in 
institutions is by far the most direct measure of the amount of 
sickness, and Table LX., calculated from the census returns, 
shows for England and Wales how preponderantly public 
institutions are occupied by the sick and not the healthy. 
Deaths are taken at the average for 1891-95 and 1901-03 respec- 
tively, the difference between these and the deaths for 1891 and 
1 90 1 being immaterial for the present purpose. 

Table LX 

Per 100,000 of Total Population and per 100 Deaths in Total 
Population there were in 





Workhouses 










including Work- 


Hospitals. 


Lunatic 


Total 




house Infirmaries 


Asylums. 


Institutions. 




and Schools. 








d 


d 


a 


d 


d 


d 


d 


d 




_ 


d 





G O 





c 





c 




Inmates 
per 100,00c 
tal Populati 


Deaths per 
00 Deaths i 
tal Populati 


Inmates 
per 100,00c 
tal Populati 


Deaths per 
00 Deaths i 
tal Populati 


Inmates 
per 100,00c 
tal Populati 


Deaths per 
00 Deaths i 
tal Populati 


Inmates 
per 100,00c 
tal Populati 


Deaths per 
00 Deaths i 
tal Populati 







w O 





<-" O 





w 





•"■ 




H 


H 


H 


H 


H 


H 


H 


H 


1891 . 


630 


7*i 


95 


3*5 


276 


IT 


1001 


117 


1901 . 


641 


8-i 


120 


5-5 


280 


i*5 


1041 


I5-I 



The fraction of deaths in the total population occurring in 
public institutions was accordingly fifteen times as large as the 
fraction of the total population which was housed in these 
institutions. 

Apart from figures of mortality, the nearest approach to a 
satisfactory index of tuberculosis is probably to be found in the 



268 THE PREVENTION OF TUBERCULOSIS 

number of the pauper population. It is the last part of the 
population to be reached by ameliorating influences tending to 
control tuberculosis, and would therefore be expected to have a 
higher sickness rate than the general population, and to yield 
figures of which the variations will correspond with some accuracy 
to the variations in prevalence of tuberculosis. We have seen 
that this theoretical expectation has been verified, at least for 
the United Kingdom, in the close co- variation of the numbers 
of paupers and of deaths from tuberculosis respectively over 
a long period ; and the numbers of paupers relieved during the 
periods here in question do therefore actually represent on some 
scale those of total cases of tuberculosis during the corresponding 
periods. 

In using these indirect measures of institutional treatment 
of tuberculosis and of its prevalence, it must be remembered 
that they are indirect and approximate. Thus, for instance, 
figures for institutional treatment usually give the number of 
cases and not days of treatment, and while they tell how many 
people were segregated in institutions, do not show the average 
duration, still less the quality of the treatment. Any of 
these indirect forms of segregation ratio has therefore to be 
verified wherever possible by the application to the same com- 
munity and period of one or more other forms of the ratio, and 
checked where practicable by a special examination of sample 
constituent communities whose figures are included in the total. 
This has been done so far as the information obtainable has 
allowed. It will be seen that the results obtained by applying 
different ratios to the experience of the same country and period 
are usually, though not invariably, in good agreement ; and 
where this is not the case, fortunately other data have been 
available to explain the discrepancy and enable a more correct 
segregation ratio to be formed. 

Where, again, the segregation ratio — the proportion of sick 
days spent by consumptives in institutions — is expressed as the 
proportion of total paupers who receive indoor relief, it is assumed 
that the number of days of sickness is the same in each class. 
This assumption is probably incorrect ; but to such extent as 
consumptives admitted to indoor relief are, in fact, treated 
longer than the average of other paupers, the error would be to 
exhibit the extent of segregation as being less than it really is, 



AMOUNTS OF INSTITUTIONAL SEGREGATION 269 

and for the present purpose the figures may therefore be used 
with safety. 

As has been pointed out previously, the phthisis rates with 
which these ratios should be compared are not those for the same 
but for a somewhat later period, the interval representing the 
time taken for the effect of segregation to show itself. For the 
present purpose this comparison can in any sufficiently long 
series of years be made with the phthisis figures of the same year, 
not because the phthisis is affected immediately by simultaneous 
changes in other phenomena, but because the numerical differ- 
ence between closely consecutive phthisis figures in the present 
material happens to be small. 

The countries in which the fullest records of experience have 
been obtained in regard to institutional segregation are England 
and Wales, Scotland, and Ireland. It is not always realised how 
large a proportion of the total population is at any one time in 
public institutions ; and, without quoting the actual figures, 
Table LXI. shows to the nearest whole number the number of 
total population at the censuses of 1891 and 1901 to every one 
inmate of a public institution. 

Table LXI 

For every Inmate of a Public Institution the Total Population of the 

Country was 





England and Wales. 


Scotland. Ireland. 


1891 .... 
1901 .... 


99 
96 


! 
164 82 
137 69 



The figures available for England and Wales and for London 
permit a statement of the fraction of total deaths in the popula- 
tion occurring in institutions, which, as we have seen, is one of 
the measures of the amount of institutional segregation. Tables 
LXII. and LXIII. give these figures, together with those of the 
death-rate from phthisis for a considerable period. They show that 
the decrease in phthisis was accompanied by a large and steady 
increase in institutional segregation measured by the fraction of 
total deaths occurring in institutions ; and the rate at which 
these changes occurred is shown more conveniently in Figs. 



270 



THE PREVENTION OF TUBERCULOSIS 



33 and 34, in which the rate of change of the phthisis death-rate 
is shown by the side of the rate of change of the segregation 
ratio, the curve for the segregation ratio being inverted as shown 
on the left-hand scale. 



Table LXII. — England and Wales 
Percentage of Total Deaths in Public Institutions 



Years. 


Workhouses 

and 
Workhouse 


Hospitals. 


Lunatic 
Asvlivms. 


Total 
Institutions. 


Death-rate i 

per 1000 of ] 

Population 

from 

Phthisis. 

1 




Infirmaries. 


. ., 






1869-70 


57 


1-9 


07 


8'3 


2'45 
(1866-70) 


I87I-75 • 








8-8 


2*22 


1876-80 






6'3 


2-4 


0-9 


9-6 


2*04 


1881-85 






6-6 


2-9 


I/O 


10-5 


I-8 3 


1886-90 






67 


3 '4 


i'i 


1 1 '2 


I -6 4 


1891-95 






7-2 


3*9 


i-i 


12*2 


1*46 


1 896-1900 






77 


4-6 


l 'i 


137 


I'32 


1901-03 




8'5 


5 '9 


i-8 


16*2 


1-23 



Table LXIII. — London 
Percentage of Total Deaths in Public Institutions 







Public, 








Death-rate 


Years. 


Workhouses 

and 
Workhouse 
Infirmaries. 


LU a n n a d tiC ' M ' 
Imbecile 
Asylums. 


A. B. 

vitals. 


Other 
Hospitals. 


Total 
Institu- 
tions. 


per 1000 of 

Population 

from 

Phthisis. 


1852-55 • 


9'6 


07 






167 




1856-60 . 


9-0 


o-6 






i6'3 




1861-65 . 


9-0 


0-4 






l6'2 


2-80 


1866-70 . 


9-1 


o-5 






i6'3 


2-86 


1871-75 . 


9-8 


o'5 






17-3 


2-51 


1876-80 . 


ii'3 


o'4 






18-6 


2-40 


1881-85 . 


12-3 


0-4 






20-5 


2'II 


1886-90 . 


11*8 


1-9 c 


>7 


87 


23-1 


i-88 


1891-95 • 


I3-3 


2*o : 


vo 


9'4 


267 


i-87 


1 896- 1 900 


14-8 


2*1 2 


VI 


IO'2 


29-2 


i-8o 


1901-03 . 


177 


2'8 J 


>"2 


12*2 


347 


1-65 
(1901-04) 



Thus in England and Wales, in the period 1866-1903, segrega- 
tion measured by the fraction of total deaths occurring in in- 



AMOUNTS OF INSTITUTIONAL SEGREGATION 271 

stitutions has approximately doubled, and the death-rate from 
phthisis has approximately halved ; in London segregation has 
not quite doubled and the phthisis death-rate is rather more 
than half. The closeness of numerical correspondence may be 
and probably is accidental, for, as pointed out above, close 
numerical concordance is not to be expected in the courses of 
complex associated phenomena operating among other complex 
influences. The data show, however, not only a very close 




Fig. 33. — England and Wales. Logarithmic Curves showing Rates of Change in 
the Phthisis Death-rate and in the Proportion of Institutional to Total 
Deaths from all Causes 

correspondence between the increase of total institutional 
segregation measured by the ratio in question and the decrease 
of phthisis, but an even more striking similarity in the rates at 
which these changes have occurred. The experience is summar- 
ised in the high correlation coefficients of '91 for England and 
Wales (1878-1903) and '90 for London (1866-1904). 



272 



THE PREVENTION OF TUBERCULOSIS 



The experience so far as it is available of the chief individual 
classes of institutions exhibits the manner in which this result 
has been obtained. 

Workhouse infirmaries have been the most important agency 



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Fig. 34. — London. Logarithmic Curves showing Rates of Change in the Phthisis 
Death-rate and in the Proportion of Institutional to Total Deaths from all 
Causes 



in segregation. These institutions are used to a much greater 
extent for tuberculosis than in the earlier history of poor-law 
administrations. Figs. 27 and 28, expressing the data of Tables 



AMOUNTS OF INSTITUTIONAL SEGREGATION 273 

LXV. and LXVL, have shown the general reduction which has 
occurred in total pauperism side by side with the steady mainten- 
ance of indoor relief at a stationary level in England and Wales, 
and an actual increase of indoor relief in London. In 1848-49 
over 60 out of every 1000 inhabitants of England and Wales 
were paupers as against 20 in 1902-03. The whole of the re- 
duction was in persons receiving outdoor relief, and the number 
of indoor paupers remained stationary at from 7 to 8 per 1000 
of population. Thus of the total pauper population, who, as we 
have seen, are the most subject to disease of all kinds and notably 
to tuberculosis, the segregation in workhouses in 1848-49 amounted 
to about one-eighth, and was increased by 1902-03 to over one-third. 
The fact expressed in these figures is explained by Mr. Fleming, 
who speaks of the " great change in the character of workhouse 
inmates during recent years. . . . The able-bodied inmates are 
gone and the sick inmates have come " (1902-03, p. 84). When 
the frequency of tuberculosis is remembered, these figures and 
this fact become equivalent to the statement that, as has been 
seen already for the total institutions for England and Wales, 
there has been during a period of vast reduction in tuberculosis 
also a vast increase in the extent of segregation of tuberculous 
patients in workhouse infirmaries. 

As a matter of practical importance, individual inquiry has 
been made among 27 Boards of Guardians in London and 85 
of the chief provincial towns, to ascertain the extent to which 
workhouse infirmaries treat consumptives in separate wards. 
In 12 of the metropolitan infirmaries out of the 27, consumptives 
were treated wholly in the same wards as other patients, and in 
only 9 were they treated entirely in separate wards. Out of the 
85 provincial infirmaries only 23 treated consumptives wholly 
and 13 partially in separate wards. It appears therefore that, 
although separate treatment is not rare, the more common 
practice is to treat consumptives in general wards. Incidentally 
it may be observed that taken in context with the general reduc- 
tion in the prevalence of phthisis, this fact is very striking evidence 
of the superiority of segregation in infirmaries over what is 
practicable at home, and agrees well with the general considera- 
tions to which attention was drawn on p. 258. It must be 
remarked further that, although these results show great good 
to have arisen without the use of separate wards, it is obviously 
18 



274 THE PREVENTION OF TUBERCULOSIS 

desirable to have consumptive patients treated separately when 
it can be arranged. 

Figures are not available in most cases to express the duration 
of stay of consumptives in workhouse infirmaries . For all diseases 
the average number of days' stay for each patient in certain 
provincial infirmaries in 1 897 was: Salford,97; Leeds, 95 ; Croydon, 
86; Birmingham, 74; West Derby, 60; Kensington, 48. From the 
nature of the disease the stay of consumptives was probably longer 
on the average ; thus in Kensington in 1897 all patients had 
an average stay of 48 days, consumptives of 144 days in 1898 
and 95 in 1902. In Sheffield in 1904 the average stay of each 
phthisical patient was 311 days, and in Brighton 221 days. 
While therefore the segregation of each patient must have 
extended over a large portion of the period of his illness, there is 
considerable variation in the period of segregation in different 
towns. The existence of this variation indicates that while 
increased segregation in institutions has been followed by de- 
crease in phthisis in various towns and countries, the decrease 
caused by institutional segregation must have varied at least 
according to the differences in average duration of treatment 
and according to any other variations in the efficiency of the 
segregation. 

After workhouse infirmaries, the most important institutions 
for segregation of tuberculosis are lunatic asylums. The per- 
centage of lunatics treated with relatives and others was 18*4 
in 1859, and fell to 5*5 in 1902. The death-rate from tubercu- 
losis in borough and county asylums in 1901 was 15*8 per cent, 
of the inmates, or over ten times as great as in the general popula- 
tion. Of these tuberculous lunatics the majority were tuber- 
culous on admission, according to the results of Dr. Mott 
(1905). Subject therefore to such allowance as maybe required 
by the fact that lunatics seldom expectorate, 1 the segregation 
of each tuberculous lunatic has been equivalent to the with- 
drawal from the community of ten ordinary tuberculous persons. 
The proportion of lunatics in asylums to the total population in 
1902 was over 0*3 per cent., and their segregation must therefore 
be taken to have been equivalent to the withdrawal of say 3 per 
cent, of normal population or the same amount of average 

1 They are often dirty in their habits, and large numbers of tubercle bacilli 
must be passed in the faeces. 



AMOUNTS OF INSTITUTIONAL SEGREGATION 275 

infection from the community. The average stay of each 
patient is about five years, or far longer than in any other great 
class of institutions. When the considerable increase in the 
extent to which lunatics are now lodged in asylums is considered, 
it is evident therefore that during the period of decline of tuber- 
culosis a large, sustained and increasing segregation of tuberculous 
patients has taken place in these institutions. 

The disproportion between accommodation and need in the 
case of special hospitals is too great for them to have had a large 
effect on the total amount of tuberculosis. In the past con- 
siderable numbers of consumptives were treated in general 
hospitals, but the returns of most of them show an increasing 
unwillingness to admit such patients. Thus in the Royal 
Infirmary (general hospital) of Glasgow the proportion of 
total deaths due to phthisis has fallen from 16-9 per cent, to 
4 per cent. With this decrease of treatment of phthisis in 
general hospitals has been associated the great increase of its 
treatment in workhouse infirmaries. 

The experience of large towns has been similar to those of 
the whole country. For the reasons described on p. 207, the 
experience of small towns into and out of which there is much 
migration is, like the experience of separate quarters of large 
towns, of very doubtful value. In certain towns the segregation 

Table LXIV 





Brighton. 


Sheffield. Salford. 




Proportion 

Phthisis Per of 
TW4.V. Total Deaths 
De f h " from 
rate ' Phthisis in 
, Institutions. 


Phthisis 
Death- 
rate. 


Proportion Proportion 
Per Cent, of p , , . . Per Cent, of 

Total Deaths p&!xh- Total Deaths 

from from 

Phthisis in > ™ e ' Phthisis in 

Institutions. J Institutions. 


1866-70 . 2-95 9-6 

i87i-75\ 2 ., 7 ' „., 
1876-80/ * i 247 n 7 2-23 
i88i-8 5 \ 1-90 
1886-90 J * l 9 -> I43 170 
1891-95 \ j. 6 , ic .q i*5* 

1896-1900J • l6 -> • ■sa ,- 3S 

I9OI-O4 .1 1*40 20*2 I*25 a 


'e'-s ::: ::: 

7-9 ... ... , 

10-3 2-36 I4'4 X 
14-3 1-94 19-2 

20'0 178 23-5 

26-1 2 1-82 : 27-6 



1884-90. 



- 1901-05. 



276 THE PREVENTION OF TUBERCULOSIS 

ratio has been obtained in the more direct form of the part of 
the total deaths from phthisis which occurred in institutions. 
Of the total deaths in London from phthisis, 31*4 per cent, in 
1889 and 33*5 per cent, in 1904 occurred in workhouses, work- 
house infirmaries, and sick asylums ; in Sheffield the proportion in 
workhouse infirmaries and sick asylums was in 1876-80 only 6*3 
per cent., and it rose in 1901-05 to 26*1 per cent. ; in Salford in 
1884-90 it was 14*4 per cent., rising to 27*6 per cent, in 1901-04 ; 
in Brighton it was 9*6 in 1866-70, rising to 20*2 per cent, in 
1901-04. The course of these figures is set out in Table LXIV. 
by the side of the phthisis death-rate for the towns in question, 
and, as was seen in the country as a whole, and for institutions 
as a whole, there is shown constant increase of segregation in 
workhouse infirmaries accompanying constant decrease of 
phthisis. 

Coefficients of correlation summarising this correspondence 
for a long series of single years work out at '67 for Salford 
from 1884 to 1904, and *8o for Sheffield from 1876 to 
1905. 

Summarising all this experience, it will be seen that in England 
and Wales a large and continuously increasing amount of insti- 
tutional segregation of phthisis, measured by the fraction of 
the total mortality occurring in institutions, has been accom- 
panied for nearly forty years by a large and continuous decrease 
of the disease, and that throughout the entire period each of 
these changes has gone on at much the same rate as the other. 
The same association appears when segregation is measured 
in the more direct form of the fraction of deaths from phthisis 
in the whole community occurring in institutions as seen in 
the experience of certain large towns. 

These results may now be compared with those obtained by 
regarding segregation as measured by either the fraction of 
total pauperism which is treated in institutions, or the ratio 
in which the number of paupers treated in workhouses and 
workhouse infirmaries stands to the total number of deaths 
from phthisis in the community. The results obtained in either 
of these ways confirm the conclusion obtained by the use of the 
other measures of segregation. 

Table LXV. is a summary in quinquennial periods of the 
data for this comparison for the individual years from 1866 to 



AMOUNTS OF INSTITUTIONAL SEGREGATION 277 
Table LXV. — England and Wales 









DO Of 


Segregation Ratio. 


Number per 100,0 






Population of 




For every ioo Indoor 

Paupers there were the 

following Number of 


Deaths from 


Indoor 


Total 


Deaths from 


Total 




Phthisis. 


Paupers. 


Paupers. 


Phthisis. 


Paupers. 


1866-70 . 


245 


726 


4652 


34 


641 


1871-75 . 


222 


662 


3828 


31 


578 


1876-80 . 


204 


668 


2982 


31 


446 


1881-85 . 


183 


730 


2870 


25 


393 


1886-90 . 


164 


709 


2749 


23 


388 


1891-95 . 


146 


687 


2489 


21 


362 


I 896-1900 


132 


692 


2356 


19 


340 


1901-03 . 


123 


688 


2218 


18 


322 



1903. A clearer view of the total result is given in Table LXVI., 
which shows for England and Wales, and also for London, the 
respective percentages which the phthisis death-rate and the 
segregation ratio in question of 1901-03 are of the corresponding 
figures of 1866-70. 

Table LXVI 



In 



England and Wales 
London . 



Phthisis 

Death-rate for 

1901-03 as 

Per Cent, of 

Phthisis 

Death-rate for 

1866-70. 



50 
5S 



_, . Indoor 

Rat '° ivsr 

Pauperism 

for 1901-03 as 

Per Cent, of 

same Ratio for 

1866-70. 



5° 
3S 



Ratio 



Indoor Pauperism 



Total Phthisis Deaths 
for 1901-03 as Per Cent, 
of same Ratio for 
1866-70. 



53 
44 



This experience for the entire series of individual years is 
expressed by a coefficient of correlation of — '94 between segre- 
gation measured by the fraction of pauper population treated 
in institutions and the phthisis death-rate. 

The rate at which segregation, measured by comparison 
of indoor and total pauperism, has varied is shown in context 



278 



THE PREVENTION OF TUBERCULOSIS 



with the rates of variation of the death-rate from phthisis in 

Fig. 35- 

Each of these results is closely similar to that obtained 
by the previous measures of segregation. In the whole country 
segregation, measured in any of the ways, has approximately 
doubled, while the death-rate from phthisis has been halved. 



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Fig. 35. — England and Wales. Logarithmic Curves of Phthisis Death-rates 
and of Ratio of Indoor to Total Paupers, 1861-65 to 1901-03 

In London exactly the same has happened ; measured by the 
fraction of the pauper population treated in institutions, the 
amount of segregation has more than doubled. 

No figures are available for Scotland or Ireland by which 
segregation can be expressed in terms of institutional deaths. 
Measured by the other ratios, the data for Scotland are given in 
Tables LXVII. and LXVIIL, and in Fig. 36. 



AMOUNTS OF INSTITUTIONAL SEGREGATION 279 
Table LXVIL — Scotland 









Number per 100,000 of 


Segregation Ratio. 










Population of 


For every 100 Indoor 










Paupers there were the 










following Number of 


Deaths 

from 

Phthisis. 


Indoor 
Paupers. 


Total 
Paupers. 


Deaths 

from 

Phthisis. 


Total 
Paupers. 


1866-70 . 


259 


253 


3896 


102 


I540 


1871-75. 






248 


224 


3210 


in 


1433 


1876-80 . 






230 


235 


2597 


98 


1 105 


1881-85 . 






211 


236 


2742 


89 


1 162 


1886-90 . 






188 


224 


2168 


84 


968 


1891-95 . 






176 


212 


1978 


83 


933 


I 896- I 900 






168 


227 


2085 


74 


919 


1901-03 . 


147 


242 


1922 

! 


61 


794 




A. 



Q. %> 



Fig. 36.— Scotland. Logarithmic Curves of Phthisis Death-rates and of 
Ratio of Indoor to Total Paupers, 1861-65 to 1901-03 



28o 



THE PREVENTION OF TUBERCULOSIS 



In Scotland as in England the facts for the two terminal 
periods as given in the following table bring out more clearly 
the relationship between the different factors. 



Table LXVIIL— Scotland 



Phthisis Death-rate 

for 1901-03 

as Per Cent, of 

Phthisis Death-rate 

for 1866-70. 



56 



_ . Indoor _ 

Ratio T Pauperism 

for 1901-03 

as Per Cent, of 

same Ratio 

for 1866-70. 



52 



Ratio 



Indoor Pauperism 
Total Phthisis Deaths 

for 1901-03 
as Per Cent, of 

same Ratio 

for 1866-70. 



60 



As in the experience of London, the proportionate extent 
of segregation appears to have been somewhat larger when 
measured by the ratio of indoor to total paupers than when 
measured by the more direct ratio of indoor paupers to total 
deaths from phthisis in the whole community. On both 
measures, however, these data show very close correspondence 
between increased segregation and decrease of the death-rate 
from phthisis; and in the more direct segregation ratio, given 
in the 3rd column approximately, the same numerical closeness 
appears between the increase of segregation and the decrease 
of the phthisis death-rate as was seen in the experience of 
England and Wales and of London ; a decrease of the phthisis 
death-rate of about 56 per cent, having been associated in 
Scotland with an increase of about 60 per cent, in institu- 
tional segregation. As with England and Wales, the rates 
at which segregation has increased throughout the entire period 
have been much the same as the rates at which the death-rate 
from phthisis have declined. The experience is summarised 
by a coefficient of correlation of — "91 between segregation, ex- 
pressed as the fraction of total pauperism treated in institutions, 
and the phthisis death-rate. 

The data for Ireland are given in Tables LXIX. and LXX. 

In Ireland a decrease in the amount of institutional segrega- 
tion has been accompanied by an increase in the death-rate 
from phthisis ; and measured by the more direct segregation 
ratio, there is again numerical identity between the extent 



AMOUNTS OF INSTITUTIONAL SEGREGATION 281 



Table LXIX. — Ireland 













Segregation Ratio. 




Number per 100,000 of 
Population of 


For every ioo Indoor 

Paupers there were the 

following Number of 


Deaths 

from 

Phthisis. 


Indoor 
Paupers. 


Total 
Paupers. 


Deaths 

from 
Phthisis. 


Total 
Paupers. 


1866-70 . 

1871-75. 
1876-80 . 
1881-85. 
1886-90 . 
1891-95 . 

I 896- I 900 
1901-03 . 




182 
190 
200 
208 
213 
214 
213 
215 


963 
882 

903 
1019 

954 
906 

944 
947 


1233 
1389 
1569 
2198 

2332 
2204 
2244 
2272 


19 
22 
22 
20 
22 
24 
23 
23 


128 
158 

174 
215 

244 
243 
237 
240 



Table LXX. — Ireland 



Phthisis Death-rate 

for 1901-03 

as Per Cent, of 

Phthisis Death-rate 

for 1866-70. 



118 



_ . Indoor „ . I . Indoor Pauperism 

Ratio T . Pauperism Ratio 



for 1901-03 

as Per Cent, of 
same Ratio 
for 1866-70. 



186 



Total Phthisis Deaths 

for 1901-03 
as Per Cent, of 

same Ratio 

for 1866-70. 



121 



to which the death-rate from phthisis has increased and the 
extent to which institutional segregation has decreased. In 
two respects, however, the experience of Ireland appears to 
differ from that of England and Wales and of Scotland. The 
absolute amount of segregation, although steadily decreasing, 
has nevertheless, so far as gross figures are concerned, been 
greater than in England and far greater than in Scotland, while 
the phthisis death-rate has not only increased but has from 
1881-85 onwards been higher than in England and from 1886-90 
onwards than in Scotland. Moreover, the rates at which the 
apparent extent of segregation has changed in Ireland during 
the period in question show much less numerical concordance 
with the corresponding changes in the phthisis death-rate than 



282 THE PREVENTION OF TUBERCULOSIS 

has been seen in the experience of England and Wales and of 
Scotland. Each of these discrepancies is merely one of quantity 
and not of kind, and leaves segregation and the death-rate 
from phthisis varying universally as in England and in Scotland. 
Their explanation throws a light on the practical working of 
institutional segregation. 

Theoretically the discordance might be due to one or more 
of three causes. The concordance in England and in Scotland 
might have been mere coincidence. This explanation, as will 
be seen shortly, is inadmissible because the comparison of in- 
stitutional segregation with phthisis in a considerable number 
of other countries shows similar concordance. Presuming 
therefore that institutional segregation tends to reduce phthisis, 
it might be that in Ireland the influence of factors tending to 
increase phthisis has been greater than in either of the other 
countries. To some extent this has probably been the case ; 
but although it might assist in explaining the greater prevalence 
of phthisis at the present time in Ireland than in England or 
Scotland, it has no bearing on the increase in Ireland itself, 
unless Ireland at the present time is in a worse economic and 
sanitary condition than in the past, which, as already seen, is 
not the case. An examination of the demographical and adminis- 
trative conditions of the country gives, however, independent 
and direct explanation of the lower specific result produced by 
institutional segregation in Ireland. It has been seen already 
that the population of Ireland contains a smaller proportion 
than either England or Scotland of persons at the ages specially 
liable to die from phthisis, and a higher proportion of persons 
at the ages when pauperism mostly occurs. Apart, therefore, 
from any question of specific efficiency, the specific result of 
pauper segregation must have been lower in Ireland than in 
England or in Scotland. This apparent reduction of specific 
result of segregation in workhouses is the greater because, as is 
shown in the Reports of the Irish Local Government Board, 
many artisans and labourers when sick, in the absence of other 
medical institutions, resort to the workhouse infirmary for all 
classes of diseases ; and their cases, which would include a 
much lower proportion of tuberculosis than occurs among 
paupers, swell the figures of apparent segregation. So much 
is clear as to the specific result of what appears as segregation 



AMOUNTS OF INSTITUTIONAL SEGREGATION 283 

in Irish experience, apart from any question of its specific 
efficiency. There is, however, unanimous and conclusive 
evidence that the quality of the segregation is notably inferior 
in Ireland to that given in England or in Scotland. The extent 
of institutional segregation is greater in Dublin than in the 
rest of Ireland, the indoor paupers in the Unions of North and 
South Dublin numbering 94 per 1000 in 1903, as compared 
with 80 per 1000 in the rest of Ireland. The average stay of 
each pauper in workhouses in North and South Dublin is 70 days, 
in the rest of Ireland 39 days. Clearly therefore the institutional 
segregation of phthisis may be taken to be more extensive in 
Dublin than in the rest of Ireland. Yet Sir Charles Cameron 
(Ann. Rep. 1904, p. 31) says concerning Dublin : — 

:< The hospitals rarely keep consumptives whose cases are 
hopeless, to the termination of their disease by death. If such 
cases were retained in hospital, it would prevent the circulation 
of much tuberculous infective matter." 

This statement is confirmed by the data contained in a return, 
kindly supplied by Mr. J. E. Devlin of the Irish Local Govern- 
ment Board, which has enabled me to calculate the average 
duration of residence of phthisical patients in the Dublin work- 
houses. It is shown in the following table, in comparison with 
similar returns for English workhouses. 

Table LXXI 

Average Reside?ice (in Days) of all Phthisical Patients in Workhouses, to 
Time of Discharge or Death (not including Patients still in the 
Institution) 



I 

I 




Based on Experience of the 

Undermentioned Number of 

Patients who have 


Institution. 


Days. 




Left the 


Died in the 






Institution. 


Institution. 


North and South Dublin Workhouses 








: 1904-05 

; Brighton Infirmary, 1 897- 1 905 . 
, Kensington Infirmary, 1888 " . 


53 
175 
144 


272 
165 

107 


156 

181 

68 


I „ ,, 1902 

| Sheffield (Firvale) Infirmary, 1904 


95 
3ii 


151 


112 

... 



284 THE PREVENTION OF TUBERCULOSIS 

The above return relates to North and South Dublin, which in 
1903 had a population of 379,666. 

It will be noted that, unlike the experience of Kensington 
Infirmary (see p. 274), the institutional residence of consumptive 
patients in the Dublin workhouse is less than that of all patients 
in the aggregate. 

In addition to the necessarily low specific effect of segrega- 
tion in Ireland due to the constitution of the population, to 
the much shorter duration of average residence in workhouse 
infirmaries in Ireland than in England or in Scotland, and to 
the very imperfect conditions of Irish workhouses which diminish 
the efficiency of segregation, the great increase in outdoor relief 
must have exerted a powerful influence in promoting the pre- 
valence of tuberculosis, owing to its inevitable effect in increasing 
domestic at the expense of institutional treatment, and to its 
effect in continuing an enormous number of domestic foci of 
tuberculous infection such as are invariably implicated in the 
average home treatment of phthisis among the poor. 

On these grounds the lower specific value of institutional 
segregation in Ireland need not be taken into further con- 
sideration. 1 

The experience of the United Kingdom will now be com- 
pared with that of foreign countries, and it will be seen that 
the inquiry is carried into a larger number than was used in 
examining the other factors of phthisis. This course is desirable 
in regard to segregation and was unnecessary for the other 
factors, because each of the factors discussed earlier in this paper 
showed failure to maintain co-variation between the factor and 
the phthisis death-rate in one or more of the countries examined . 
This failure does not appear when segregation is tested over the 

1 Comparisons have been freely made in this inquiry between the condition 
of different countries at a given period as regards food, housing, etc. ; but the 
necessity of caution in making a similar comparison between different countries 
as regards segregation has been emphasised. The reason for this is obvious. 
Such factors as a given amount of food, of house accommodation, wages, etc., 
mean much the same in any country, and can with approximate accuracy be 
compared with the corresponding phthisis death-rates in each country. It is 
otherwise with segregation until we can obtain more accurate measures of its 
duration and its character as well as of the number of segregated persons. 
Administrative variations like those shown in the experience of Ireland are 
enormous ; and country can only be compared with country so far as the general 
trend of observation goes. Each country needs separate study as to the 
contents of any institutional segregation which its statistics show. 



AMOUNTS OF INSTITUTIONAL SEGREGATION 285 



1901-02. 

192 per 100,000 of Population x 



same countries, and it is therefore necessary to extend the inquiry 
over a wider area in order to make sure that the continued con- 
cordance was not fortuitous. 

The death-rate from phthisis in Norway (1904, p. 30) was — 

1881-90. 1891-1900. 

141 189 

In 1902, of the total deaths in Norway 5*9 per cent, 
occurred in hospitals and lunatic asylums. The average 
duration of treatment of all the patients treated in hospitals in 
1902 was 35 days. It is evident, therefore, that there is com- 
paratively little institutional treatment of sickness in Norway 
as a whole, together with increasing phthisis. Separate hospital 
statistics could not be obtained for Christiania, but facilities 
for hospital treatment are doubtless more extensive than in 
the rest of Norway, and there has been considerable fall in its 
phthisis rate. 

No Swedish statistics for the entire country are obtainable. 

Table LXXII 
Death-rate per 100,000 of Population from Phthisis 





1861-70. 


1871-80. 


1881-90. 


1891-1900. 


All Swedish towns together . 
Stockholm ..... 
Gottenburg ..... 
All other towns .... 


306 

433 
279 

195 


324 
406 
326 
299 


300 
346 
322 
277 


270 
292 

303 
256 



Stockholm is the only town of Sweden showing any marked 
decline in its phthisis rate. The detailed statistics show, both 
in small and large towns, either insignificant declines, or a 
stationary phthisis rate. There are few hospitals in Sweden, 
as shown by the following extract from the report to the Paris 
Congress on Tuberculosis (1905, p. 205) : — 

" Notwithstanding the excellent general organisation of 
Swedish hospitals, only a small number of consumptives can 
be treated in them, owing to the fact that the great majority 
of the hospitals were organised only for the case of acute diseases. 
The official figures for 1890-1900 show that only about 1500 
tuberculous patients have been treated each year in all the 
provincial hospitals of the kingdom, while the number of 

1 See footnote on p. 213. 



286 



THE PREVENTION OF TUBERCULOSIS 



patients suffering from tuberculosis is about 60,000 (1905, 

P . 4)." 

Stockholm is better furnished with hospitals than the other 
towns, and it alone shows any decline of phthisis, though its 
death-rate is still very high. 1 

As regards Denmark, statistics are obtainable only for Copen- 
hagen. These have been kindly furnished by Dr. E. M. Hoff. 



Table LXXIII. — Copenhagen 
Phthisis and Hospital Treatment 







Percentage of the 


Cases of Phthisis 




Phthisis Death-rate 


Total Deaths from 


treated in Hospitals 


Years. 


per 100,000 of 


Phthisis which 


Per Cent, of Total 




Population. 


occurred in 


Deaths from Phthisis 






Hospitals. 


in the Population. 


1860-64 . 


307 






1865-69 








297 






1870-74 








342 






1875-79 








314 


... 




1880-84 








289 


30 


77 


1885-89 








251 


27 


88 


1890-94 








205 


25 


83 


1895-99 








183 


28 


80 


1900-04 . 


149 




147 



Evidently there is, as Dr. Hoff states, a large amount of 
institutional treatment of phthisis in Copenhagen ; and he adds 
that the average number of days' treatment for each patient 
has in recent years increased much more rapidly than the number 
of patients. More recently, further particulars have been 
published (1905, p. 7). It is stated that — 

" Notwithstanding the enormous increase of accommoda- 
tion required, owing to the growth of the town and new ideas 
concerning phthisis, up to the present all requests for admission 
have been satisfied ; and no consumptive desiring to be admitted 
has hitherto been refused owing to lack of room." 

In 1895, on an average 40 beds in the municipal hospitals 
were always occupied by consumptives (deaths from phthisis 



1 R. Koch quotes Carlsson's statement that 410 cases of pulmonary phthisis 
are being cared for in the hospitals of Stockholm, " no small number for a city 
of 300,000 inhabitants " (Lancet, 26, v. 1906, p. 1450. 
the Fight against Tuberculosis now stands"). 



Nobel Lecture on " How 



AMOUNTS OF INSTITUTIONAL SEGREGATION 287 

in that year in Copenhagen, 661) ; in 1904, the number of beds 
thus always occupied was 270, not including the Sanatorium 
of Boserup (deaths from phthisis in Copenhagen in 1904 were 
632) . The mean duration of treatment of three successive series 
of cases of phthisis, in years 1890-1904, was as follows : — 



Table LXXIV. — Copenhagen 





Mean Duration of 


Mean Duration of Stay (Days) in 
Hospital of Patients 


in Days. 


Dying in the 
Hospital. 


Leaving the 
Hospital. 


Series I. . 
„ II. . . 
„ III. . . 


40 
107 
107 


42 

112 

98 


40 
105 
no 



The reduction of phthisis in Copenhagen, therefore, has been 
associated with a large amount of institutional treatment of the 
disease in general hospitals. The co- variation of the phthisis 
death-rate for Copenhagen during the period of 1880-1904 and of 

Table LXXV 







Prussia. 




Berlin. 


Rate per 


100,000 of 


; For every 


Rate per 


100,000 of 


For every 




Population of 


100 Deaths 

from 

Tuber- 


Population of 


100 Deaths 

from 

Tuber- 










Years. 






culosis the 






culosis the 






Cases of 


Number 




Cases of 


Number 




Deaths 


Tuber- 


of Patients 


Deaths 


Tuber- 


of Patients 




from 


culosis 


. with Tu- 


from 


culosis 


with Tu- 




Tuber- 


treated in 


berculosis 


Tuber- 


treated in 


berculosis 




culosis. 


General 


treated in 


culosis. 


General 


treated in 






Hospitals. 


1 Hospital 

was 




Hospitals. 


Hospital 
was 


1877-80 . 


319 


43 


14 


337 


231 


69 


1881-85 • 


3ii 


53 


17 


332 


255 


77 


1886-90. 


291 


65 


23 


294 


282 


96 


1891-95 • 


248 


77 


31 


244 l 


291 l 


119 


1 896- 1 900 


212 


9i 


43 


213 


313 


147 


1901-02 . 


192 


124 


64 


210 


284 


136 



1 Returns for 1891 missing. 



288 THE PREVENTION OF TUBERCULOSIS 

the deaths from phthisis which occurred in the hospitals of 
Copenhagen is summarised in a correlation coefficient of "57. 
When segregation is measured for the same period by the pro- 
portion of cases of phthisis treated in hospitals to total deaths 
from this disease, the coefficient of correlation with the phthisis 
death-rate is '68. These figures (Table LXXV.) express a fair 
co-variation between segregation as measured above and the 
phthisis death-rate. 

Table LXXV. shows that, while in the whole of Prussia the 
number of cases of tuberculosis treated in general hospitals has in- 
creased from 14 for every 100 deaths from this disease in 1877-80 
to 64 per 100 deaths in 1901-02, the death-rate from tuberculosis 
has declined from 3*19 to 1*92 per 1000. Similarly in Berlin 
the number of cases treated in Berlin has increased from 69 
per 100 deaths from this disease in 1877-80 to 136 per 100 deaths 
in 1901-02. 

There is reason for believing that the duration of treatment 
as well as the number of hospital patients has increased. It 
will be noted (Table LXXV.) that the proportion of cases treated 
in hospital was greater throughout in Berlin than in Prussia. 
Collateral evidence shows that the duration of treatment of 
each patient has been shorter in Berlin than in Prussia. Ap- 
proximately while Berlin had 153 beds (for all patients in its 
general hospitals) for every 100 in Prussia, it had 241 patients 
for every 100 in Prussia, for equal populations. 

The above experience is summarised in correlation co- 
efficients between the annual returns of segregation and of 
phthisis or tuberculosis death-rates of '95 for Berlin and '93 for 
Prussia, showing close co- variation of the two phenomena. 

It will be remembered that the general hospitals indicated 
above are not sanatoria. The limited operation of the latter 
has already been described on p. 254. 

In Brussels the death-rate from tuberculosis has declined 
from 3*21 per 1000 in 1886-90 to 1*97 in 1901-03. In the two 
great hospitals of Brussels (St. Jean and St. Pierre) the number 
of deaths from tuberculosis to every 100 in the whole city was 
I2'2 in 1886-90, 15*6 in 1891-95, 173 in 1896-1900, and 38*9 
in 1901-03. I am unable to obtain further information as to 
the character and duration of the hospital segregation of con- 
sumptive patients in Brussels, but the experience of Brussels 



AMOUNTS OF INSTITUTIONAL SEGREGATION 289 

appears to fit in with that of Copenhagen and of English towns. 
The correlation coefficient between the annual segregation 
ratios from 1888 to 1903 and the corresponding phthisis death- 
rates in Brussels is 76. 

In 1902, 4828, i.e. 41 per cent, of the total deaths from 
tuberculosis of the lungs and larynx in Paris occurred in its 
public hospitals. The average duration of stay in hospital of 
all patients admitted to its general hospitals was only 23*6 
days in 1901 (Dr. J. Bertillon). The institutional treatment of 
phthisis in Paris is very short, and can have but little effect 
in preventing infection. We have already seen that in Paris 
there is probably no considerable decline of the death-rate 
from phthisis, and that it remains much higher than that of any 
other city for which statistics have been obtained. 

There is among the medical profession of Paris an impression 
that the Paris hospitals are a focus for tuberculous infection. 
Thus, M. Mesurier states that the hospital attendants " suffer 
cruelly from contagion in the wards, two-thirds of them be- 
coming tuberculous (1905, p. 9)." He states also (1905, p. 16) 
that the hospitals contain 30 to 40 per cent, of consumptives. 
On the other hand, Dr. S. Bernheim, Vice-President of the 
Societe Internationale de la Tuberculose (1905, p. 173), states : — 

" The Paris hospitals scarcely suffice for patients suffering 
from acute diseases, and can only, in view of their number, 
exceptionally admit consumptives. Furthermore, all the 
hospitals in our large centres of population, were they restricted 
to the treatment of tuberculosis, would not suffice for a tenth 
part of the consumptive poor of these towns." 

The two statements here quoted can be partially reconciled 
by the fact that Paris hospitals are generally so overcrowded 
that consumptives make a very short stay in them. 

Dr. Bernheim, in a later paragraph, says : — 

" A consumptive never improves in our hospitals. We 
can allow the death in one of our beds of a consumptive with 
cavities ; and, on the contrary, the curable consumptive has 
his fever increased in the presence of patients with serious 
lesions ; and, in the inevitable overcrowding, rapidly passes 
beyond the first stage of the disease, and on leaving the hospital 
has no further prospect of recovery. In this sombre statement I 
leave out of consideration the contamination of the hospital ; 
19 



290 THE PREVENTION OF TUBERCULOSIS 

and do not wish to speak of the unhappy typhoid patient who 
often leaves the hospital with consumption which he has acquired 
there." 

On the whole, it may be said that in balancing the possibilities 
of infection in Paris homes and hospitals, it is doubtful on 
which side the dangers are greatest. These hospitals, with a 
few exceptions, cannot under recent conditions be regarded 
as institutions tending to reduce total infection. As a whole, 
neither the extent of accommodation nor the average length 
of treatment is comparable with what is found in other countries. 
This, coupled with the uncertainty of the death returns, would 
make it unsafe to include the French statistics, even if they 
were available, in the consideration of the problem. 

In the cities of the United States a considerable and increasing 
proportion of cases of phthisis are institutionally treated. In 
Cincinnati, in 1885, i8 - 6 per cent., and in 1902-04, 34*6 per cent., 
of the total deaths from phthisis occurred in its public institu- 
tions. In San Francisco, in 1885-87, 30 per cent., and in 1902- 
04, 38 per cent., of the total deaths from phthisis occurred in 
its public institutions. In New York, in 1884, the death-rate 
from phthisis was 3*86, in 1903 it was 2*40 per 1000 of popula- 
tion. In 1882-84, 22*o per cent., and in 1901-03, 26*0 per 
cent., of the total deaths from all causes occurred in public 
institutions. Dr. Hermann Biggs writes me that he cannot 
give separately the number of deaths from phthisis in the public 
hospitals of New York ; but he states that a census of tuberculous 
patients in the public institutions in the boroughs of Manhattan 
and the Bronx has been taken twice a year for a series of years, 
and that the number of beds available for phthisis has greatly 
increased. At the present time there are 2100 to 2200 beds, 
chiefly for the care of advanced cases. Fifteen years ago the 
number specially devoted to this purpose was scarcely more 
than a quarter of this number, certainly not in excess of one- 
third. He adds that in little more than a year they will probably 
have over 3000 beds for tuberculous patients : though even 
this number is insufficient. The number of deaths from phthisis 
in Manhattan and the Bronx in 1903 was 5250. This implies — 
assuming the above beds to be always occupied — that every 
advanced case of phthisis in the city has had in recent years 
an opportunity of being segregated in a hospital during 21 



AMOUNTS OF INSTITUTIONAL SEGREGATION 291 

weeks. Doubtless a smaller number, representing the poorest 
and therefore the most dangerous part of the phthisical popula- 
tion, were segregated for a correspondingly greater part of the 
year. 

During the years 1881-1903 the coefficient of correlation 
between the phthisis death-rate and the proportion of deaths 
occurring in public institutions was 75. This figure in itself 
shows a well-marked co-variation of the phenomena in question. 
Its significance is the more notable when it is considered in 
connection with the amount of overcrowding in New York. 



CHAPTER XXXVI 

THE RELATIVE INFLUENCE OF INSTITUTIONAL SEGRE- 
GATION AND OF OTHER MEASURES FOR THE CON- 
TROL OF TUBERCULOSIS 

THE results disclosed by Chapters XXVIII. to XXXIII. may 
be said to have added nothing of practical value to the 
knowledge described in Part I. of this volume. They 
indicate the probability that tuberculosis is affected to a greater 
or less extent by general sanitary conditions, town life and over- 
crowding, and the various elements of well-being ; but the 
probability disclosed in this way is not so strong as that result- 
ing from the facts given in Part I., which indeed place the con- 
nection beyond doubt. Neither line of investigation, however, 
has succeeded in measuring the respective extent of influence 
exerted by the important factors in question. 

The experience of institutional segregation differs from 
that of the other factors of the death-rate from tuberculosis, 
both because the nature of its influence on the prevalence of 
the disease cannot be inferred with certainty from the facts 
given in Part I., and because not only the nature but the relative 
extent of this influence is demonstrated clearly from the statis- 
tical results. On theoretical grounds it has long been recognised 
that the institutional segregation of patients suffering from 
an infectious disease may influence its prevalence in two ways. 
It may restrain the disease by segregating foci of infection 
from the general population, or it may spread it by exposing to 
infection from these foci persons in or about the institutions not 
suffering from the disease in question. With tuberculosis it has 
till recently been a moot point whether these theoretical results 
actually appear in practice, and which of them is the more 
important. The records of segregation analysed in the pre- 
ceding pages give a decided answer to this question. Each 

group of records shows, not as a matter of hypothesis or theory, 

292 



MEASURES FOR CONTROL OF TUBERCULOSIS 293 

but as the teaching of actual experience, which [gives the final 
touchstone for final conclusions and action, that with no more 
precautions than are taken in well-conducted general infirmaries 
the increase of institutional segregation has been associated 
with reduction of tuberculosis in the community affected by it ; 
and that the segregation of a decreased proportion of the total 
bulk of tuberculosis has been associated with an increase of 
the disease. The scale of the observations and the number of 
communities examined is so large as to eliminate the chance 
that this correspondence has been due to mere coincidence ; 
and it follows that these associations of segregation, with 
the prevalence of tuberculosis, have not been accidental, but 
have occurred because segregation has had an influence on 
the disease, and because it has done more to restrain infection 
than to spread it. 

By comparing the several experiences of the communities 
examined, we have been able to obtain information as to the 
relative importance of institutional segregation and of the 
other factors of the death-rate from tuberculosis. We have 
examined the records of a large number of communities exhibit- 
ing the respective variations of the several factors affecting 
the death-rate from tuberculosis side by side with the variations 
of this death-rate. Each of these factors was thus tested in 
the actual experience of many large communities over the 
same period of history. In the series of communities subjected 
to this test, institutional segregation was the only factor of which 
the variation was always associated with a variation in the pre- 
valence of tuberculosis in a constant relative direction. It would 
not have been surprising had the influence of institutional segrega- 
tion been masked by that of opposing factors, as has been seen 
(p. 221) to have occurred in many countries with the important 
influence of urbanisation; or contrariwise, it would not have 
been surprising if more than one influence had varied with the 
prevalence of tuberculosis in a constant relation. In either 
case the question as to which influence had predominated in 
affecting the prevalence of tuberculosis would have been left 
open. In fact, however, no influence except that of institu- 
tional segregation has appeared in actual experience in a constant 
relation to the amount of tuberculosis, and it must therefore 
be accepted as having been the predominant influence. 



294 THE PREVENTION OF TUBERCULOSIS 

The administrative consequences flowing from this result 
are obvious in principle from what has been stated previously, 
and further reference in detail is made to them in Part III. 

(P- 394). 

Some general reflections may be permitted as to the method 
by which the result has been obtained. It has involved 
necessarily much repetition of inquiries concerning the factors 
of the prevalence of tuberculosis as the experience of each 
country came under review ; in many of these experiences 
questions subordinate to the main issue have had to be asked 
and answered by further reference to communal experience 
in order that doubts arising in the course of the investigation 
might be eliminated. The presentation of the argument would 
have been far simpler and easier if the number of these reitera- 
tions had been reduced and the doubts ignored ; but the results 
would have been inconclusive and intellectually dishonest. 
Those who have read this section attentively may have found 
some or all of it tedious and wearisome ; the collection, calcula- 
tion, and above all the conspective criticism of its data has 
certainly been far more tedious and wearisome. Such, how- 
ever, is the condition upon which alone the records of com- 
munities large enough to be worth studying by this macro- 
scopic method will consent to give up their secrets. 

The experience which these records contain is not arranged 
in the orderly sequence of a text-book, but is intermingled in an 
almost endless intricacy. The chief difficulty in handling it 
lies in arriving at the assurance that the material examined 
is sufficient for the purpose in view. The temptation to stop 
short of what is necessary for sound conclusions does not lie 
mainly in the reluctance to continue the protracted labour of 
accumulating, arranging, and comparing data ; nor to persons 
of elementary scientific honesty does it consist in the fear that 
continued investigation may upset conclusions previously 
reached ; but rather in the fact that many of those whom the 
solution most concerns may decline to follow the more detailed 
argument associated with protracted investigation, when it 
becomes as intricate as it has to become if the results of the 
investigation are to be trustworthy. Such investigations are 
apt to be judged by summaries which are often imperfect, 
misleading, or even inaccurate ; and the work is subjected not 



MEASURES FOR CONTROL OF TUBERCULOSIS 295 

to the welcome criticism which is based on equal labour, but 
to random and often irrelevant conjectures, hypotheses, and 
speculations. 

Although the continued search for the full truth may, as 
indicated above, even obstruct its recognition, no part of the 
search can be omitted with safety. The attempt to find a 
royal road to truth and to express it as a whole by suppressing 
essential parts, leads too often to indolent work and slovenly 
thought ; and this in the public health service is not to be 
tolerated. We are not engaged in academic labours, of which 
the prize shall go to the winner, and it is at the choice of each 
man to neglect his preparation. The servant of public health 
is working on the lives of men, and should be laying the founda- 
tions of national prosperity and happiness. He belongs to an 
order of sanitary priests, and if he forms or announces con- 
clusions without having used fully and faithfully the material 
at his disposal, he belies his vocation and abuses his trust. 
" The day is short, and the work is much, and the labourers 
are slothful, and the reward is great, and the master of the 
house presses." 

NOTE ON CORRELATION COEFFICIENTS 

The coefficient of correlation between two columns of figures is a 
number, never greater than unity, which expresses the closeness with 
which deviations of figures in one column from their mean value follow 
deviations in the corresponding figures of another column from their 
mean. In the case of perfect direct correlation, i.e. when all corre- 
sponding deviations from mean values vary in the same sense of excess 
or deficiency and bear the same ratio to each other, the coefficient is 1 ; 
in the case of perfect inverse correlation, where the senses of variation 
in corresponding pairs of figures are opposite and the ratio of their magni- 
tudes is the same, it is -1 ; and it may have any intermediate values 
according to the nature of the case. The closer the coefficient is to + 1 , 
the nearer is the approach to constant co-variation of the pairs of figures ; 
and where no influences but those represented by the figures are operating, 
a high correlation coefficient on a sufficient number of figures is the 
numerical expression of strong inductive evidence that there is some 
connection — whether causal or otherwise is a matter for subsequent 
discussion — between the phenomena represented by the two groups of 
figures. In practice it is rare for two groups of phenomena to be free 
from disturbing influences; and the correlation-coefficient measures 
therefore for practical purposes the influence of one group of phenomena 
on the other to such extent as it predominates over or is assisted by the 
other influences in operation. Within certain limits the manner in which 



296 THE PREVENTION OF TUBERCULOSIS 

the deviations are measured may vary according to the circumstances 
of the case. The effect of any such variation would, however, only be to 
alter the final result by a relatively small amount ; and coefficients of 
correlation, computed on any single system, represent the closeness 
of relations between such curves as appear in Part II. far more dis- 
tinctly than any general impression that can be derived from mere in- 
spection of the curves. The usual form taken for this coefficient is the 
ratio of the arithmetical mean of the products of corresponding devia- 
tions in each group of figures from the arithmetical means of the values 
in the respective groups to the product of the square roots of the arith- 
metical means of the sums of these deviations squared ; that is to say 



y(W(*?>' 



where x and y are the deviations from the arithmetical means of the 
respective series. 

Without discussing the precise mathematical reasons for the selection 
of this form of coefficient and the processes by which its validity is demon- 
strated, it is worth while to verify the fact that, by whatever mathe- 
matical considerations the coefficient in question may have been obtained, 
it is a quantity of which the magnitude must always depend on the closeness 
with which the phenomena to which it refers stand in some relation to 
each other. This may be seen very shortly. It can be shown by simple 
algebra, and is here assumed to have been proved, that this fraction 
can never be greater than i. If the two groups of phenomena were 
unconnected by any causal link whatever, that is to say, if there was no 
reason why a deviation x n of any figure in one group from the arithmetical 
mean of that group should be accompanied by a deviation ±y m of dependent 
magnitude and constant relative direction in the corresponding figure 
of the other groups, then in any long series of pairs the deviation of figures 
in each group from the arithmetical mean would be as often positive as 
negative, and their values would be distributed evenly on each side of 
the mean. Hence the products of the pairs of deviations (xy) of which 
the sum (2xy) forms the numerator of the fraction will be as often 
positive as negative, and when added together with their proper signs 
will exactly balance each other, and the sum will be o. In other words, 
when there is absolutely no causal link between the phenomena, this 
correlation coefficient will become o. If there is any causal link, then 
to such extent as they are governed by the causal relation the figures 
expressing the phenomena will always deviate from their respective 
arithmetical means in a common direction or always in opposite direc- 
tions ; the members of every pair of corresponding deviations will in every 
case be either both greater or both less than the arithmetical mean of 
their respective groups (i.e. always +x and +y or always -x and -y), 
or else in every case one will be greater and the other less (i.e. always ±_x 
and +r). Therefore the products of which the sum enters into the 
numerator will either always be positive or always be negative, and the 



MEASURES FOR CONTROL OF TUBERCULOSIS 297 

sum total of the products will accordingly be either a positive or a negative 
quantity of which the magnitude will depend on the number of terms 
to be added. It follows therefore that the more the co-variant terms, 
the larger will be the numerator ; and as the whole coefficient can never 
exceed +1, the closeness with which its value approaches +1 will be a 
measure of the closeness with which the phenomena under examination 
are connected by cause directly or inversely. 



PART III 

MEASURES FOR THE REDUCTION AND 
ANNIHILATION OF, TUBERCULOSIS 



CHAPTER XXXVII 

GENERAL NATURE OF PREVENTIVE MEASURES: 
INDIRECT MEASURES 

IN Part I. and Part II. of this volume we have discussed 
in full the causation of phthisis, and the factors which have 
produced the decline already secured in the death-rate 
from this disease. It has been seen that, on the one hand, an 
infective agent, the tubercle bacillus, is the essential agent in 
causation, and that, on the other hand, various influences other 
than infection favour or inhibit the spread of the disease. If 
our review of the factors of past decline of phthisis is correct, 
the diminution of infection outweighs in importance the diminu- 
tion of the conditions favouring infection, though historically 
the two have been acting in combination in most countries. 
To remove infection most completely we must have the earliest 
diagnosis of disease. The early recognition of an infectious 
disease is therefore the first step in preventive measures against 
it. The cases recognised thus early must then be notified to 
those whose duty it is to inaugurate and ensure the execution 
of measures against further spread of infection, and to discover 
its source in the notified case. This must be some other case 
of the same disease, either human or animal ; and the detection 
of the source, when practicable, will enable wider measures 
to be taken against infection ; while at the same time the 
removal or improvement of the conditions, which in the instance 
in question have favoured infection, will aid in preventing the 
occurrence of further cases. Around the notified case centre 
our further preventive measures, which are none the less 
preventive in character because they consist largely in the 
most effective treatment of the patient himself. Wherever 
practicable, the sanatorium treatment of the patient at an 
early stage will be secured, with a view to his cure and to his 
being trained in the details of the hygienic life which offers 



302 THE PREVENTION OF TUBERCULOSIS 

him the best prospect of recovery and of efficiency after re- 
turning home. Should recovery not be secured, the hospital 
treatment of the patient, especially if he is poor and cannot 
secure good nursing at home, is indicated at a later stage ; and 
if he recovers but partially, the conditions for modified work 
under favourable conditions need careful consideration. All 
these and many allied problems require to be studied, and 
some attempt at stating the principles of action is made in the 
following chapters. In this chapter we may now consider in 
outline the indirect measures against phthisis, which in the 
aggregate are very important in its prevention. 

Indirect Measures against Phthisis. — The Teaching of the 
Laws of Health. — Of these measures the most important of all 
is the inculcation of the laws of health. Hygiene should be 
one of the most important subjects in the curriculum of every 
scholar in the higher classes of our elementary schools, and 
every teacher should be thoroughly competent to teach it. 
In a paper read before a Conference of Medical Officers of Health 
in 1890, I pointed out that as the entire school population 
passed through the higher standards in our elementary schools, 
we had here the means of systematically teaching the science of 
health to at least six-sevenths of the entire population of the 
next generation ; but that for this purpose " it was necessary that 
teachers competent to teach the subject should be provided." 
The same opinions have been frequently expressed ; and it is 
satisfactory to find it stated in a circular issued by the Board 
of Education in November 1907 that that Board " are urging 
the necessity of giving special instruction in the principles of 
hygiene to all students in every type of training college, so that 
they may be able to deal profitably with this subject in the 
schools." With such teaching in schools and the correlative 
practice of school hgyiene, each school will gradually become 
an example of the application of the laws of health, and the 
homes of the people will quickly benefit also. 

Fresh Air and Cleanliness. — In such a scheme of teaching 
hygiene the importance of an abundance of fresh air, of strict 
cleanliness of person and environment, and particularly of avoid- 
ance of dust, will be emphasised ; and thus something will be 
done towards securing three great conditions for the prevention of 
phthisis. The importance of nasal breathing will also be taught, 



GENERAL NATURE OF PREVENTIVE MEASURES 303 

as a means of filtering the incoming air, and of preventing the 
formation of adenoids, which are a favourite nidus for tubercle 
bacilli. If, as appears to be the case, artificial feeding with 
the ordinary bottle-teat, and particularly the constant use of 
the " dummy-teat, " favour the production of adenoids, an 
additional reason is furnished for the abolition of the latter 
and the encouragement of breast-feeding of babies. The 
dangers of dust illustrate the need for having school-drill and all 
gymnastic exercises on dustless floors and in an atmosphere 
which approximates to that of the external air. 

Ill-nutrition and Fatigue. — Defective nutrition may favour 
tuberculosis, either by allowing latent foci to come into activity 
or by favouring new infection. Over-fatigue is a contributory 
influence similar to ill-nutrition, in which the toxic effect of the 
products of fatigue replaces the effect of inanition ; and in context 
with over-fatigue, it is convenient to group the ordinary occupa- 
tional disadvantages which combine with over-fatigue to lower 
the inhibitory powers of the workers, favouring catarrhs, and 
rousing into activity foci of infection, which may have remained 
latent in the bronchial or other lymphatic glands for many 
years (pp. 74 and 137). In the poor the two often unhappily 
coincide. If food is carefully chosen, even the very poor seldom 
suffer from dangerous mal-nutrition ; but if bread and tea 
alone take the place of porridge, cheese, herrings, with bread 
and other very cheap but highly nutritious foods, mal-nutrition 
opens the way to a dangerous extent to invading tubercle 
bacilli. Over-fatigue probably causes a much larger number 
of attacks of tuberculosis than mal-nutrition, and much of the 
excess of pulmonary tuberculosis among men as compared with 
women is due probably to this. It is not suggested that there 
is not abundant infection in the workshops ; nor that the dust 
of workshops is not largely responsible for the result under 
consideration. If a reliable test for the limits of physiological 
fatigue were applicable, which would eliminate the element of 
personality in the testing, and would enable work to be given 
in accordance with individual fitness, much avoidable disease 
might be prevented. At present we are without any such test, 
capable of being used in practical life. 

Alcoholism. — Alcoholism, like excessive fatigue, loads the 
circulation with toxic matter, diminishes the normal phagocytic 



304 THE PREVENTION OF TUBERCULOSIS 

action of the body cells, and makes the individual more prone 
to every form of infection, and especially to tuberculosis. As 
already seen, alcoholic indulgence, when it involves the frequent- 
ing of public - houses, implies increased risk of infection by 
tuberculosis (pp. 159 and 181 ; and it is scarcely practicable in 
most instances of phthisis among the intemperate to distinguish 
between the two factors. It is fairly clear, however, that even 
among those classes of intemperate persons, who have not been 
exposed to convivial infection, an excessive death-rate from 
phthisis prevails. 

Poverty. — There is no need to reconsider in detail the relation 
of poverty to phthisis, as Part II. is largely devoted to this 
problem. Poverty and tuberculosis are allied by the closest 
bonds, and nothing can be simpler or more certain than the 
statement that the removal of poverty would effect an enormous 
reduction of the death-rate from tuberculosis. It is, however, 
essential in order to secure clear conceptions of causation, to 
investigate" differentially in various communities the separate 
operation of overcrowding, ignorance, mal-nutrition, increased 
opportunities for infection, as constituent elements of poverty. 
This has been done in pp. 224 to 255, and the preceding remarks 
as to the teaching of hygiene, the removal of over-fatigue and 
mal-nutrition, the encouragement of alcoholic temperance, and 
of cleanliness, represent the practical issue of this investigation. 
There remains to be considered the influence of housing. 

Housing Conditions. — Although the death-rate from phthisis 
is not proportional to the quality of the housing accommodation 
in compared communities (pp. 225 and 229), the death-rate from 
this disease in any given community is always higher among 
those badly than among those more favourably housed (p. 147). 
That improved housing is not the main influence determining 
the past decline in the death-rate from phthisis is shown by the 
evidence given on pp. 227 and 228. This does not imply that 
improved housing accommodation is not imperative in the public 
interest, but only that such improved accommodation has not 
been the predominant influence in causing the decline of the death- 
rate from phthisis. 

Other things being equal, however, every improvement in 
conditions of housing will secure a diminution of tuberculosis. 
This applies both to structural and to functional conditions 



GENERAL NATURE OF PREVENTIVE MEASURES 305 

of housing ; to improvement in respect of light, air, and ventila- 
tion ; and to improvement in internal cleanliness of dwelling- 
rooms, and diminution of overcrowding. Dwellings to which 
light gains free access will always be kept cleaner than dark 
and sombre dwellings ; sunlight has a special purifying action 
of its own (p. 53) . But even more important than these important 
structural conditions is the manner of using the dwelling-rooms. 
The structural improvements owe a large share of their import- 
ance to the fact that they render internal cleanliness easier, and 
its absence more quickly detected. In many houses, unfortun- 
ately, bedrooms are overcrowded, while other rooms remain 
partially or completely unoccupied. The teaching of the laws 
of health, the reduction of the waste of money on alcoholic 
drinks, the elevation of the moral standard, must gradually 
diminish this variety of overcrowding. As already indicated, the 
best means for diminishing the risks of overcrowding is to secure 
the institutional treatment of the sick (pp. 149 and 224), especially 
of the tuberculous sick. This brings us back to the evil done by 
overcrowding in favouring the spread of infection ; in this 
chapter we are concerned with its action in lowering the resist- 
ance to infection ; and although this must be placed on a lower 
platform than the direct effect in spreading infection, every 
effort must be made persistently to spread out the sleeping 
accommodation of each family over all the rooms available for 
this purpose, and to insist on the increase of this accommodation 
as required. This latter problem is one of the most difficult 
in practical sanitation. To secure its complete solution involves 
a wider attack on the problems of poverty, and an increase of 
the family income in some instances, and in others a determined 
attempt to prevent the waste of the family resources in dis- 
sipation and gambling (see also p. 206). 



20 



CHAPTER XXXVIII 

THE EARLY RECOGNITION OF PHTHISIS IN RELATION 
TO ITS PREVENTION 

THE Need for Better Organisation of Medical Treat- 
ment. — For both its successful treatment and the com- 
plete prevention of spread of infection, phthisis must 
be recognised at an early stage. A very large proportion 
of cases, especially those occurring among wage-earners, are 
not diagnosed until some such serious symptom as pleurisy or 
haemoptysis (spitting of blood) occurs. Even when pleurisy 
occurs, this acute disease is often treated without the phthisis 
which it commonly indicates being diagnosed. Under the 
present conditions of medical treatment immediate improvement 
in the expedition with which phthisis is diagnosed cannot be 
anticipated. For the working man can seldom afford to leave 
his work until actually disabled ; and too often he cannot afford 
to pay a doctor's fee for treating a cough, which he may regard 
as of comparatively small importance. The provident system 
of medical attendance has not been generally successful in this 
country, and is not likely to become so in the absence of com- 
pulsory membership. Even when adopted, its full benefits 
have not been secured, in part owing to the absence of arrange- 
ments for consultations, where necessary, with physicians having 
special experience in chest ailments. My views on this point, 
which has a most important bearing on the prevention of tuber- 
culosis, are set forth in the following remarks taken from a 
recent address (Sept. 1907). 

Doctors have never been doing so much and such good work 
on behalf of the public as at present ; but this work is being 
done under conditions involving the petty worries of fee- 
collecting, the stress of competitive commercialism, the strain 
of work which for most doctors is excessive in order to secure 
a " living wage," and the " sweating " of the medical profession 



THE EARLY RECOGNITION OF PHTHISIS 307 

by hospitals, friendly societies, and similar organisations. 
The doctor earning his livelihood among the artisan and labouring 
classes not only has to do excessive work under harassing con- 
ditions without leisure, but he is in a large measure cut off from 
consultation with doctors having special knowledge in the very 
considerable proportion of complicated cases which come under 
his care. To the patient in the same classes the conditions 
are equally unsatisfactory. However willing he may be to 
pay the doctor's fee — which maybe as low as is. 6d., or even 6d. 
— his limited means necessitate delay in obtaining medical aid 
until compelled by urgent symptoms, and necessitate dis- 
pensing with this aid at the earliest possible moment. He 
realises also the absence of skilled consultation in difficult cases, 
and that by attending at a hospital to which his employer has 
subscribed, or to which he in his workshop has given his penny 
a week, he may have an additional chance of being thoroughly 
overhauled, and of securing special skill. Even if the patient 
is a member of a club or provident dispensary, similar reflections 
apply under the present unco-ordinated conditions, in which 
facilities for skilled special consultations are not organised. 
Thus, in a large proportion of the total mass of sickness, the 
medical welfare of the public is not secured, partly because the 
rates of remuneration of club doctors and of doctors attending 
the poor are so scanty that only doctors of exceptional mental 
and physical capacity can afford time or energy to examine 
each patient thoroughly, and partly because medical con- 
sultations cannot be secured in difficult cases. 

The following are some of the principal respects in which 
the present medical service frequently fails : — 

1. Diagnosis is belated. This is inevitable for the largest 
proportion of the population, under circumstances which involve 
payment of a fee or seeking for a hospital letter and then waiting 
several hours in an out-patient department. The dangers of 
delaying diagnosis are too well known to need detailed con- 
sideration. ... In chronic infectious diseases, like phthisis, the 
difficulty of obtaining early diagnosis is nearly as great as with 
acute infectious diseases, and in non-infectious diseases the 
normal condition among the masses of population, especially 
those who do not belong to clubs, is to shirk medical advice 
until it becomes relatively ineffective. 



308 THE PREVENTION OF TUBERCULOSIS 

2. Treatment is curtailed and its efficiency diminished by 
similar considerations of expense. 

3. When patients are treated under present circumstances 
in dispensaries and in out-patient departments, the waste of time 
involves a serious economic loss to the community. 

4. There are no co-ordinated arrangements for medical con- 
sultations in all difficult cases. 

5. Valuable information as to the incidence of disease is wasted 
under the present conditions of medical service. 

6. There is a great waste of information as to the existence of 
conditions conducing to disease, which might promptly be re- 
moved under more systematised conditions of medical attend- 
ance. At the present time sanitary inspectors and health 
visitors are busily engaged in inspecting houses, without medical 
knowledge and with only haphazard and very occasional 
information of the conditions in the households of the poor, 
which the poor-law medical officer, the dispensary doctor, and 
the " 6d. doctor," know to be aiding the continuance of disease 
and preventing its banishment. The one set of officials, unless 
indefinitely multiplied, cannot properly locate the foci of mis- 
chief ; while poor-law and dispensary doctors and the doctors 
generally among the poor are in possession of information of urgent 
importance to the public health; information which, under present 
conditions of inco-ordination, is almost entirely lost. Over- 
crowding and dampness of the house occupied by a bronchitic 
or consumptive patient, the uncleanly and careless nursing of 
children, the numerous minor cases of food poisoning, are 
examples of conditions of direct importance to the public health ; 
and the present system must be regarded as both extravagant 
and inefficient, inasmuch as it fails to bring all available informa- 
tion concerning such conditions systematically and punctually 
to the knowledge of a properly organised system of preventive 
medicine. My meaning will be made clearer by giving a practical 
instance of co-ordination in further detail. It must be noted 
that the co-ordination required in the interests of the public 
health is not solely that between all medical practitioners, 
preventive and curative, but also between them and such 
officials as sanitary inspectors, health visitors, and nurses ; and 
the efficiency of co-ordination may be measured by the extent 
to which steps taken for the control of a single disease are 



THE EARLY RECOGNITION OF PHTHISIS 309 

applied without cost to the direct control of general sanitary 
conditions. 

The experience of Brighton in the notification of pulmonary 
tuberculosis is an instance of successful co-ordination of measures 
for the treatment and prevention of this disease with those for 
the entire public health control of the town. The Public Health 
Department of the town is the focus of all the measures — pro- 
phylactic, curative, and sanitary — which are taken in the treat- 
ment and the prevention of this disease. The officer who visits 
the notified case obtains full particulars of the sanitary condition 
of the patient's home and secures the necessary disinfection 
and sanitary improvements. He obtains information as to the 
health of other occupants of the house, and directs them into 
the avenues of medical relief, supplying hospital letters when 
a private doctor cannot be afforded. He arranges the removal 
of the patient to the sanatorium if the doctor considers this 
desirable, and there the patient is trained and treated, so that 
when discharged there is little risk of his continuing to infect 
others. It will be seen that under such an arrangement — an 
arrangement which would be improved under a system in which 
the doctor himself would to a large extent take the place of 
the inspector — one visit serves several ends, and automatically, 
and without expense, the information which it affords is dis- 
tributed to the departments really concerned. By this co- 
ordinated arrangement an economy of time, energy, and money 
is secured, which would be impracticable if separate authorities 
administered the departments concerned. . . . Hospital reform, 
as a measure by itself, would not cure either the grievances 
of the public or of the medical profession. Even were all free 
dispensaries and all out-patient departments of hospitals 
abolished, the willingness and competence of patients to pay 
sufficient fees would not thereby be increased, nor would the 
ability of the general practitioner to do excessive work for 
insufficient pay. 

Yet at the present time the coexistent but unco-ordinated 
systems have failed lamentably to provide what the health 
of the community requires — means for ensuring effectively 
the early recognition and proper treatment of all disease. I 
hope and believe that what has been done already towards 
securing this end is merely a phase in the evolution of the system 



3 io THE PREVENTION OF TUBERCULOSIS 

which will attain it ultimately. The total expense under a 
co-ordinated system, worked with due economy, might or might 
not be greater than that entailed under the present inefficient 
and unco-ordinated system ; and it may be asked whether 
the increased cost can be justified economically. The economical 
justification, as I have already indicated, will be found in the 
decrease of sickness which must follow, with the corresponding 
decrease of poverty and inefficiency and invalidity ; in other 
words, the economical, like the medical, justification and com- 
mendation of a complete medical service consists in its being 
a branch of a general service of preventive medicine. 

I see no reason to expect that such a medical service, whether 
partial or general, would tend to deprave any part of the com- 
munity morally, any more than the system of free (that is rate- 
paid) education has tended to pauperise the parents of the 
children who benefit by it. There would be, I think, no diffi- 
culty in proving that each additional form of medical aid 
officially given up to the present time, so far from undermining 
self-help, has imposed new duties and responsibilities on the 
recipients of such help ; while in the aggregate these measures 
have been largely instrumental in securing the immense im- 
provement in the public health already realised. 

Some essential features of the medical service to which 
I look forward will be obvious from my previous observations. 
At present we have medical officers of health dealing with 
sanitation and the prevention of infection, poor-law medical 
officers dealing with sickness under the most adverse home 
circumstances, school doctors and nurses knowing nothing 
or next to nothing of the home conditions which baffle their 
work, factory surgeons out of touch with local public health 
administration, and a large body of private practitioners daily 
in touch with environmental evils that they cannot remove. 
The picture which this mere enumeration calls up of work which 
overlaps in some directions and leaves serious gaps in other 
directions, and which in both instances means an enormous 
waste of knowledge of enormous value to the public health, 
shows that systematic co-ordination is indispensable to medical 
as well as to economical efficiency. The considerations previ- 
ously advanced indicate that on all grounds the extended 
medical service must be primarily a preventive service. It 



THE EARLY RECOGNITION OF PHTHISIS 311 

must be a medical service for the general community and not 
merely for its sick members, and must call into activity every 
individual and collective means for the preservation of health 
as well as for the cure of disease. Information of pre- 
ventive value must no longer be allowed to run as at present 
into culs-de-sac, but must be utilised to the full extent for 
the public welfare. This can only be effected when pre- 
ventive medicine is regarded as a whole, and the many frag- 
mentary portions of it — now unconnected and relatively in- 
efficient — are no longer allowed to continue relatively impotent ; 
and when every branch of curative medicine is included in its 
scope. 

The Removal of Ignorance. — Next in importance to the 
removal of all hindrances to early treatment comes teaching 
the public the significance of the early symptoms of tuberculosis. 
This will doubtless be done in connection with the instruction 
in hygiene in the higher classes of elementary and other schools. 
Such facts as the following if thoroughly realised would go far 
towards annihilating this disease. 

1. Consumption is curable, in the majority of instances, if 
treated at an early stage. 

2. Every cough not yielding to ordinary treatment within 
a limited period, indicates the necessity for (a) thoroughly 
examining the patient's chest, and (b) examining the patient's 
expectoration for tubercle bacilli. 

3. Every case of pleurisy must be regarded as likely to be 
followed by consumption, failing persistent attention to a 
hygienic life. 

And there is no reason why this knowledge should not be 
impressed upon every boy and girl before leaving school, as 
well as upon those who have already left school. At the same 
time it should be made plain that scrofulous glands, abscess 
of bones, and some deformities of the spine are due to tuber- 
culosis. 

On the part of doctors practising among the masses of the 
population much more needs to be done to ensure the early 
recognition of tuberculosis. More time needs to be spent in 
ascertaining the antecedents of each patient, his exposures 
to infection, and the method of onset of the symptoms from 
which he is at present suffering. 



312 THE PREVENTION OF TUBERCULOSIS 

Diagnosis by History. — Symptoms otherwise obscure are 
often at once elucidated when an accurate history is obtained 
from the patient. The occurrence of languor and lassitude, 
of occasional "bad colds" or "bronchitis," of a persistent 
cough for some weeks, of indigestion and " anaemia," — one or 
more, or all of them at different times — may indicate merely 
passing sickness, or may form the early symptoms of phthisis ; 
and the significance of these symptoms can often be discovered 
by obtaining an accurate domestic and personal history from 
the patient. 

The diagnosis by history, — aided by such symptoms as the 
above, — is in reality a diagnosis of 

The so-called Pr^e-tuberculous Stage. — Reference to 
the schemes on pp. 64-70 and 75-77 shows that there is 
strong reason for believing that in many cases of phthisis 
years of primary latency have elapsed between the reception 
of the tubercle bacilli with the formation of the first nodule of 
disease, and the first recognisable symptom of disease. In 
some cases, doubtless, resistance is steadily and increasingly 
lowered by the reception of further doses of infective material. 
In other cases, active tuberculosis is due probably to the quicken- 
ing of the long latent primary foci. This stage of primary 
latency cannot correctly be called a prae-tuberculous stage, as 
infective nodules are already present; but it is known under 
this name, and in it no clinical evidence of tuberculosis is found. 
It is in this stage that the greatest good can be done. 

The patient can be suspected of being tuberculous, and 
action taken accordingly. Given a complete system of notifica- 
tion of phthisis, or a system fairly complete among the classes 
whose children attend public elementary schools, it is possible 
to pay special attention to the children of notified cases. This 
is already done to a considerable extent, but action on these 
lines is capable of wide extension. In Brighton the notified 
cases, chiefly parents, are removed to the Borough Sanatorium 
for a month's treatment and education in the management 
of their illness ; and hospital tickets are pressed on any members 
of the family who show the least sign of failing health, and who 
cannot afford a private doctor. Scholars from such families 
should receive special preference in any scheme for providing 
country holidays. They are already given special preference 



THE EARLY RECOGNITION OF PHTHISIS 313 

in the provision of free breakfasts and dinners for the poor in 
connection with elementary schools. Extensions of action on 
these and allied lines, combined with the more frequent medical 
inspection of children from tuberculous families than of other 
children, will gradually ensure the early diagnosis and the pre- 
ventive treatment of the members of suspected families. 

Loss of Weight. — In persons of tuberculous family history 
periodical weighing is one of the best means of ensuring the 
early recognition and treatment of disease. The weight should 
be taken and recorded at least four times a year — once a month 
if there is any reason for anxiety. If along with loss of weight, 
or in children failure to increase in weight, the patient's tem- 
perature is apt to rise for apparently small reasons, the suspicion 
of tuberculosis is increased. 

Tuberculin Testing, etc. — Of means for the early detec- 
tion of tuberculosis, other than physical examinations and the 
testing of the sputum, the use of tuberculin is the best known. 
The value of this test in the detection of bovine tuber- 
culosis is well established; though, as Sir J. MacFadyean has 
pointed out — (1) an animal may not react for some considerable 
period after infection ; (2) a distinct reaction may be unobtain- 
able in some advanced cases of tuberculosis ; and (3) in a con- 
siderable number of cases a second reaction is not possible for 
some days or weeks after the first. It appears therefore that 
the reaction when it occurs is trustworthy, but that a negative 
result is less reliable. Although there are differences of opinion 
on the point, its general use as a means of diagnosis of disease 
in man is to be deprecated, in view of the possibility mentioned 
by Dr. J. E. Squire that it seemed to him to " cause an increased 
activity in the tuberculous focus." 

Calmette's Ophthalmic Method. — A local method of 
using tuberculin as a means of diagnosis has been described 
recently by Calmette, which may prove to be valuable. He 
places inside the eyelid one drop of an aqueous solution of a 
precipitate obtained by adding 95 per cent, alcohol to tuber- 
culin. If conjunctivitis develops within twenty-four hours, 
it is stated to be proof positive that the patient is suffering 
from tuberculosis ; no inflammatory reaction seems to occur in 
other than tuberculous patients. If more detailed investiga- 
tion shows that this method of employing the tuberculin product 



314 THE PREVENTION OF TUBERCULOSIS 

is harmless and free from fallacy, it promises to be very valuable 
in the diagnosis of obscure complaints which may be tuberculous. 
If it should lead to the general adoption of an earlier treatment 
of tuberculosis than has hitherto been secured, it will be an 
immense boon. 

Other Special Means of Recognition. — The Rontgen 
ray photograph of a chest in which there is an early tuberculous 
focus sometimes shows a shadow at the affected part. This is 
by no means a certain means of diagnosis, and cases have been 
described by Theodore Williams and others in which the physical 
signs (by percussion, auscultation, etc.) revealed evidence of 
disease not shown by the Rontgen rays. In fact, no special 
means of diagnosis will supersede the necessity for 

(a) careful physical examination of the patient, and 

(b) bacteriological examination of his sputum for tubercle 
bacilli. 

Physical Examination. — In cases in which there is cough 
with or without expectoration, in which the patient has repeated 
" bad colds," or in which even without these symptoms a patient 
with a tuberculous family history suffers from indigestion, 
anaemia, or languor, a thorough examination of the chest by a 
competent doctor is indicated. Such an examination will 
frequently detect the presence of lung disease, either before 
there is expectoration or before tubercle bacilli can be found 
in it. 

The occurrence of jerky breathing or of feeble inspiration is 
suspicious. A scattered fine sibilus, often heard only on deep in- 
spiration or expiration, was emphasised by Sir William Broadbent 
as important. When the physical signs are more marked and 
there is dulness and crepitation after coughing, the diagnosis 
is relatively easy, and the disease is scarcely at its earliest stage. 

Examination of Sputum. — Very commonly the disease is 
first recognised when tubercle bacilli are found in the expectora- 
tion. This cannot be regarded as satisfactory, for the occurrence 
of expectoration and the presence of tubercle bacilli in it mean 
that the encapsulation of the tubercle nodule by the surrounding 
tissues has ceased to be effective, and closed has been trans- 
formed into open tuberculosis ; non-infectious into infectious 
disease. For weeks, months, or even years in very slight cases 
the tubercle bacilli may not find their way out of the body. 



THE EARLY RECOGNITION OF PHTHISIS 315 

Thus Allbutt quotes Turban as failing to find tubercle bacilli 
in the sputum in the first stage in 59*8 per cent, of 408 cases. 

And yet in actual public health experience of the notifica- 
tion of phthisis, surprise is frequently expressed by doctors 
when sputum sent by them for examination at the public health 
laboratory shows tubercle bacilli. It is clear therefore that 
the possibilities of early diagnosis of phthisis are not realised 
in a notable proportion of cases. It must be added, further- 
more, that each year a considerable number of specimens of 
thick purulent expectoration are sent for official examination, 
from patients who have been treated — usually for bronchitis — 
for months before this step towards complete diagnosis is taken. 
I append a copy of the form of certificate of results of examination 
of sputa which is in use in my own office. 

Public Health Offices, 

Town Hall, 

_i9o 

Dear Sir, 

I beg to inform you that the specimen of sputum from 



of. 



has been exa?nined, and tubercle bacilli were 



Yours faithfully \ 



Dr. Medical Officer of Health . 

Note. — The failure to find the tubercle bacillus does not, of course, prove 
that the patient from whom the specimen was taken is not suffering from 
pulmonary phthisis. 

Tubercle bacilli can sometimes only be found after repeated examinations. 

The early morning expectoration should preferably be sent for examination. 

The patient's address should be given when each specimen is sent. 



CHAPTER XXXIX 

THE MEDICAL PRACTITIONER IN RELATION TO 
PREVENTIVE MEASURES AGAINST PHTHISIS 1 

THE Patient must not be kept in Ignorance. — When 
the presence of phthisis has been ascertained, the first 
duty of the doctor is to inform his patient. Anxious 
relatives will occasionally urge him not to do so, but the cases 
in which he is justified in withholding the information in my 
opinion are few ; and both relatives and the patient can with 
intelligent explanation be made to understand that it is in the 
latter's interest to secure intelligent co-operation between him 
and the doctor. Phthisis is an eminently curable disease. Its 
cure is hastened and rendered more certain if the patient is 
convinced of the necessity for and the wisdom of adopt- 
ing the prescribed measures, — both the treatment in the 
more limited sense of the word, and the treatment which 
consists in care as to sputum, thus diminishing the danger of 
re-infection. 

What Danger is there of Infection in Phthisis ? — 
The relative infrequency of infection of hospital nurses by tuber- 
culosis is important from the medical practitioner's standpoint, 
as a study of it supplies him with the main indications for safe- 
guarding the health of the relatives and attendants of his own 
consumptive patients. He is already aware that the channels 
of infection are limited. The following scheme sets forth the 
main dangers. This scheme does not pretend to be logical or 
exhaustive, but it serves to draw attention to some of the 
more important points : — 

1 A large part of this chapter has already been published in an Introductory 
Address given by the author at the Mount Vernon Hospital for Consumption, 
on " The Relation of the Medical Practitioner to Preventive Measures against 
Tuberculosis," Lancet, January 30, 1904, p. 282. 

316 



THE MEDICAL PRACTITIONER 317 

ri. Dose. 

I 2. Cumulative dosage. 

I. The infection. 4 3. Closeness of contact. 

I 4. Lack or absence of precautions. 

I5. Defective ventilation and cleansing of rooms. 

TT ., . . f 1, Innented - C i, Exhaustion from nursing, etc. 

II. Receptivity. A I Depress i ng emotions. 

[2. Acquired. -^ Insufficient nutrition. 

I4. Defective ventilation and cleansing of rooms. 

In hospitals, long before the communicability of phthisis 
was recognised, expectoration was received into spittoons and 
large dosage of infection was thus prevented. Similarly hospital 
wards have usually been well ventilated and kept scrupulously 
clean, all surfaces both of walls and floors being washable. 
Again, hospital nurses are not so long on duty as wives or other 
relatives, the contact between them and the patient is less inti- 
mate as well as less prolonged than that of home nurses, they 
have periodical holidays, are well fed, and are not subjected to 
the same extent to the influence of depressing emotions or of 
insanitary house conditions. They are better trained in regard 
to the washing of hands and other personal precautions. In 
view of the above circumstances, the difference between the 
infectivity characterising phthisis in hospital and in private 
practice is easily understood. 

I can imagine no better means of converting those who under- 
rate the infectivity of tuberculosis than the task of administering 
the notification of this disease in a large town, of interviewing 
some 300 patients each year, of examining over 200 patients 
who are yearly treated for a month or more each in a borough 
sanatorium with a view to train them so as to diminish the proba- 
bility of their continuing sources of infection, of obtaining the 
family and personal histories of each of these, and tracing, as 
one gradually comes to do, links of infection, which, although 
individually they may not be conclusive, when connected to- 
gether become as convincing as any evidence can ever be regard- 
ing a communicable disease of chronic course. 

Duty of the Doctor to the Patient and to the Patient's 
Family. — The first duty of the family practitioner in relation 
to a case of phthisis obviously is to do his best for the patient. 
Incidentally his position by implication involves that he is, 
at least partially, the guardian of the health of the patient's 
family. Happily, the interests of both patient and relatives 



318 THE PREVENTION OF TUBERCULOSIS 

are identical, and the measures most conducive to the patient's 
recovery will also give the maximum protection to the other 
occupants of the same house. 

Having (i) made an early diagnosis of the disease, and (2) 
acquainted the patient and his relatives with the nature of the 
disease, the further indications for the doctor are : (3) to investi- 
gate and, if possible, ascertain the most likely source of the 
patient's infection ; (4) to treat the patient (under this head 
will come not only dietetic and medicinal treatment, but the 
question of sanatorium treatment and the control of the general 
hygiene of the patient) ; (5) to train the patient to control his 
cough, as far as practicable to cough and to expectorate only when 
means are available for preventing the dissemination of in- 
fective matter, to train him to live in the open air, to eat heartily, 
and to attend to every detail of personal hygiene ; and (6) to 
protect the attendants on the patient from infection, from 
over-fatigue, from impaired nutrition, carefully training them 
on the same lines as the patient himself, whose recovery depends 
largely on the state of their health. 

Investigation of Sources of Infection. — The investiga- 
tion of possible sources of infection may appear to be somewhat 
remote from the duties of the family practitioner, and yet 
success in the treatment of the patient may be wrapped up in 
the fulfilment of this indication. The three most common sources 
of infection are : (1) domestic, (2) occupational, and (3) public- 
houses. So far as domestic infection is concerned, in well-to-do 
families the medical adviser will have the opportunity of in- 
vestigating possible unrecognised sources of infection in the 
same household. In poorer houses this is not so. The patient 
is treated as a club patient or at the dispensary or hospital. 
Domestic sources of infection cannot then be recognised by the 
medical attendant. Even if he sees the patient at home he 
has no time to investigate the case fully. It has been my 
frequent lot in visiting phthisical homes to find other unre- 
cognised patients suffering from chronic tuberculous disease 
and innocently spreading more acute tuberculous disease to 
husband or wife or children. 

If infection can be shown with some degree of probability 
to have been acquired in a dusty workshop or shop, an indica- 
tion for treatment is at once obtained. Even if the occupation 



THE MEDICAL PRACTITIONER 319 

cannot be altered, the conditions of the workshop may be favour- 
ably changed, and if the medical officer of health and the 
practitioner come into touch at this point the conditions of the 
workshop can be improved and the patient's chances of recovery 
increased without the slightest risk to the patient's pecuniary 
welfare. At this point, however, we trench on the question of 
notification of the case to the medical officer of health, and the 
action which would follow such notification (p. 338) . 

If the patient is alcoholic, to insist on a change in his 
habits in this respect, given that the patient's confidence 
can be secured and that he is open to conviction, is the 
best means not only of preparing him intelligently to carry out 
his instructions and of enabling him to recover the resist- 
ance to disease which has been lowered by alcoholic indul- 
gence, but also of stopping those visits to the public-house 
which, as Dr. J. Niven has indicated, are a frequent means of 
infection. 

Relative Magnitude of the Risks of External and 
Auto-Infection. — It may be urged that once phthisis is started 
its subsequent course is determined not by external but by 
internal infection, and that consequently the detection of the 
sources of infection or even of other cases of phthisis in the 
same house is not important from the private practitioner's 
standpoint. This point is one of real importance. In the 
card of precautionary instructions, of which a copy is given 
on p. 324, the following sentence occurs : " The patient himself 
is the greatest gainer by the above precautions, as his recovery 
is retarded and frequently prevented by renewed infection 
derived from his own expectoration." 

Is the prevention of auto-infection by expectoration, which 
has been already ejected from the mouth, important? It is 
well known that tubercle travels from one part of the body 
to another by the lymphatics or blood vessels. It is also agreed 
that healthy persons are infected chiefly by inhalation or inges- 
tion of infective dust or by direct infection by minute particles 
of ejected sputum. The patient is perhaps not likely to be 
re-infected directly by the spray of his own sputum, but may 
if this becomes dry ; and he may receive more massive re-in- 
fection if no precautions are taken to prevent the inhalation, 
as dust, of desiccated sputum, or the swallowing of his own 



3 20 THE PREVENTION OF TUBERCULOSIS 

sputum. I am unaware of any exact facts as to whether such 
re-infection is ah important factor in the downward progress of 
the consumptive when considered in comparison with the auto- 
infection caused by the cross-inhalation of infective mucus 
into other bronchioles than those first affected; but whether 
the danger be greater or less, the swallowing of sputum should be 
prohibited, and experience shows that the improvement of the 
consumptive is greatest in those cases in which there is the most 
rigid care to prevent re-infection by dust, whether because 
in this way re-infection by the tubercle bacillus or because 
secondary infection by other micro-organisms is prevented. 
I attach much importance to the value of these precautions in 
preventing danger to others than the patient. Self-interest is 
a potent motive for beneficence. 

The Effect of Swallowed Tuberculous Expectoration. 
— The occurrence of self-re-infection by swallowing expectora- 
tion is well established. Various statistics give the proportion 
of cases in which intestinal ulcers are found after death from 
phthisis, as from one-fourth to three-fourths or more of the 
total cases. The coincidence between tuberculosis of lungs 
and intestines might be due to the intestinal ulcer having been 
the primary seat of disease ; but that this is not the correct 
explanation is indicated by the fact that intestinal ulceration 
is a late phenomenon in phthisis. The intestinal disease must 
therefore in most instances be due to spread of tuberculosis 
from other parts of the body, or to the swallowing of large quan- 
tities of tuberculous expectoration. That the last is most 
usually the explanation is shown by the fact that intestinal 
ulcers are much more rarely found where the lung is not impli- 
cated, and very rarely in general tuberculosis. Experimental 
observations point to the same conclusion. Cornet records 
that out of over 3000 animals on whom he experimented other- 
wise than by feeding, only in about eight cases were tuber- 
culous foci found in the intestine and in isolated mesenteric 
glands. The extreme frequency of intestinal ulceration in young 
children and in the insane, who nearly always swallow their 
expectoration, points to the same conclusion. 

On the other hand, instances occur in which prolonged 
swallowing is not followed by intestinal ulceration. It is likely, 
also, that in a certain number of instances of such ulceration 



THE MEDICAL PRACTITIONER 321 

infection has been received from the blood current, and not by 
the direct contact of tuberculous expectoration. 

The evidence points clearly to the importance of the doctor 
warning his patient against swallowing his sputum. Some 
French physicians have gone so far as to advise washing out 
the mouth with a mild antiseptic after each attack of coughing ; 
but this does not appear to be necessary or likely to be carried 
out even if recommended. 

The Doctor in relation to Disinfection. — Assuming that 
a doctor is called in to a case of phthisis, and that up to that 
time no precautionary measures have been taken, his duty is 
not fulfilled by insisting on the adoption of all the measures 
enjoined in such a set of " precautionary instructions " as those 
given on p. 324. Infection has been repeatedly shown to cling 
to the lower part of the wall and to the floor of the consump- 
tive's room. It also hangs about his pockets, bed-hangings, 
etc. If the doctor is to do the best for his patient he must rid 
him of old infective material. And he cannot in the majority 
of instances do this alone. He must in the interest of his patient 
call in the aid of the medical officer of health, who can arrange 
for efficient disinfection of the room and its belongings. Then, 
with a rigid system of cleanliness, re-infection of the room and 
repetition of danger from this source to patient and relatives 
can be greatly diminished. 

The Doctor in relation to Notification. — Such an 
intimation of desire for disinfection is almost tantamount to 
a voluntary notification of the case to the medical officer of 
health ; and this voluntary notification can in the case of 
private patients be made only with the consent of the patient 
or his guardians. There are other reasons why such a volun- 
tary notification is desirable. 

1. The medical officer of health will probably be in a better 
position than the practitioner to detect the possible source 
of infection and thus to minimise any likelihood of continuance 
of infection when the patient resumes his occupation, etc. 

2. The medical officer of health can not only enable the 
patient to " start fair/' as indicated above, but he can do much 
to remove any insanitary conditions of home, workshop, or 
shop tending to retard recovery. It may be urged that sanitary 
authorities already have the power to abate overcrowding 

21 



322 THE PREVENTION OF TUBERCULOSIS 

and to insist on the cleansing and ventilation of houses, work- 
shops, etc. But sanitary officials are neither omniscient nor 
omnipresent, and their work is most productive of good when 
directed especially to houses in which the presence of a case 
of phthisis renders overcrowding, uncleanliness, and other 
insanitary conditions supremely dangerous. Without an army 
of inspectors it is impossible completely to control overcrowding 
and dirtiness of houses, and the notification of this disease 
gives valuable additional leverage in securing the abolition of 
minor insanitary conditions, the continuance of which is detri- 
mental to the consumptive. 

3. The most conscientious and indefatigable doctor can 
usually only ensure the carrying out of a portion of the measures 
which I have ventured to bring within the range of his legiti- 
mate duties. He may do so if his patient is wealthy and intelli- 
gent. He certainly cannot if his patient belongs to the working 
classes, who contribute the vast majority of the cases of phthisis. 
Between these two extremes are patients in whose behalf a 
varying degree of intervention on the part of the local authority 
is required. There is no wish on the part of such authorities 
or their officers to interfere, but only to help. If proper steps 
for preventing indiscriminate expectoration, for destroying any 
infective material already deposited by the patient, and for 
tracing possible connections with other cases of phthisis, have 
been taken, the less the intervention of any one between the 
medical man and his patient the better. But in actual practice 
most phthisical patients have medical men in attendance only 
at intervals, and for a short portion of their total illness. Visits 
of an educational character are certainly needed in the intervals 
of professional attendance, if not also while the latter is in opera- 
tion. In actual experience in Brighton, although a considerable 
number of cases of phthisis have been notified in private as well 
as in dispensary and hospital practice, no appreciable friction 
has been caused by my visit or those of my assistants, and a 
large amount of carelessness as to the disposal of sputum has 
been thus stopped. 

The Doctor in relation to Sanatorium Treatment. — 
A further duty to his consumptive patient devolves on the 
family practitioner. He has to decide whether he can secure 
for his patient the best medical and hygienic treatment at home, 



THE MEDICAL PRACTITIONER 323 

or whether a temporary stay in a well-organised sanatorium is 
needed. These points are more fully discussed in Chapter XL. 
As a rule, it may be said that both educationally and thera- 
peutically the patient is benefited, and his relatives are freer 
from danger of infection if such a course of sanatorium treat- 
ment and teaching has been secured. 

In the preceding remarks the ideal position of the medical 
practitioner in relation to tuberculosis has been indicated. 
Therapeutical measures are in the widest sense measures of 
prophylaxis, and the aid of measures of public and private 
hygiene is as indispensable to cure as are therapeutical measures. 
But the doctor in the majority of cases — i.e. those of the working 
classes — can scarcely be said to be the " family " doctor. Even 
in the higher social strata his efforts at prophylaxis may be 
hampered by prudential and other considerations, and he cannot 
undertake those wider inquiries which are required in order 
most completely to stop the sources of infection. Clearly, then, 
everything indicates the necessity of co-operation between 
doctor and medical officer of health, and the more complete 
this co-operation the greater is the benefit to the consumptive 
patient and to every member of the public. 



CHAPTER XL 

THE CONSUMPTIVE PATIENT IN RELATION TO 
PREVENTIVE MEASURES AGAINST PHTHISIS 

ASSUMING that the patient has consulted a doctor who is 
imbued with the ideal view of his duties suggested in 
the last chapter, the duty of the patient is clear, though 
it necessitates a steady persistence in well-doing, which implies 
moral courage and perseverance as well as intelligent accept- 
ance of the duties involved. 

The patient will have handed to him a set of instructions, 
of which the following may be taken as an example. They 
will be amplified and explained more fully by the doctor. It 
may be added that in Brighton these cards are printed by the 
Corporation without any official headings or names, in order 
that every doctor may distribute them to his own patients. 
The instructions are as follows : — 

Precautions for Consumptive Persons 

Consumption is, to a limited extent, an infectious disease. 
It is spread chiefly by inhaling the expectoration (spit) of 
patients which has been allowed to become dry and float about 
the room as dust, or by directly inhaling the spray which may 
be produced when a patient coughs. 

Do not spit except into receptacles, the contents of which are to 
be destroyed before they become dry. If this simple precaution 
is taken, there is practically no danger of infection. The breath 
of consumptive persons is free from infection, except when 
coughing. 

The following detailed rules will be found useful, both to 
the consumptive and to his friends : — 

I. Expectoration indoors should be received into small 
paper bags and burnt immediately ;^ or into a receptacle which is 

emptied down the drain daily and then washed with boiling water. 

324 



THE CONSUMPTIVE PATIENT 325 

2. Expectoration out of doors should be received into a 
suitable bottle, to be afterwards washed out with boiling water. 
If a paper handkerchief is used, this must at once be placed 
in a waterproof bag, the contents subsequently burnt and the 
bag washed daily. 

3. Ordinary handkerchiefs, if ever used for expectoration, 
should be put into boiling water before they have time to become 
dry ; or into a solution of a disinfectant, as directed by the 
doctor. 

4. Wet cleansing of rooms, particularly of bedrooms occupied 
by sick persons, should be substituted for " dusting " and 
" sweeping." 

5. Sunlight and fresh air are the greatest enemies of in- 
fection. Every patient should sleep with his bedroom window 
open top and bottom, a screen being arranged, if necessary, to 
prevent direct draught. 

6. The patient should, whenever practicable, occupy a 
separate bedroom. Children should never sleep in the same 
bedroom as the patient. 

N.B. — The patient himself is the greatest gainer by the above 
precautions, as his recovery is retarded and frequently pre- 
vented by renewed infection derived from his own expectoration. 

7. Persons in good health have little reason to fear the 
infection of consumption. Over-fatigue, intemperance, bad air, 
dusty occupations, and dirty rooms favour consumption. 

Cure and Prevention are inseparable. — The first point 
needing to be grasped by the patient thoroughly is that 
measures for the cure of and measures for the prevention of 
consumption are to a large extent identical. Certain drugs 
have their value in treating consumption ; cod-liver oil is equally 
valuable in treating it and in preventing its development ; 
most other remedial measures used in the treatment of 
consumption would be still more effective if employed in 
preventing it. 

The essential points in the treatment of consumption are — 

(1) the prevention of further infection ; 

(2) the prevention of the inhalation of dust of any kind ; 

(3) the improvement of nutrition of the patient ; 

(4) regulated rest until the disease has become entirely 
quiescent. 



326 THE PREVENTION OF TUBERCULOSIS 

The first of the above points has been discussed on p. 319. 
The patient, as well as those about him, gains by observance of 
the precautionary measures as to coughing and the disposal of 
sputum. By avoiding the swallowing of sputum, he also 
minimises the chance of secondary intestinal infection. 

The prevention of tire inhalation of dust is an essential point 
in the treatment as in the prevention of consumption. It has 
been already seen that this disease is most prevalent among 
those engaged in dusty occupations ; and one of the great gains 
in sanatorium treatment is that the patient breathes a relatively 
dustless and aseptic atmosphere. 

Similarly with regard to mal-nutrition and over-fatigue, 
the probability of recovery from consumption and of successful 
resistance to its infection, other things being equal, are both 
increased by diminishing or removing their operation. 

Home Treatment. — These points being settled, we may 
consider in detail the part which the patient has to play in 
curing his disease and preventing its spread. In this chapter 
the matter will be considered from the standpoint of the treat- 
ment of the disease at home. The following are the main 
points : — 

(1) There must be no spitting into handkerchiefs, nor should 
handkerchiefs with which the mouth has been wiped be placed 
under the pillow. The exact details as to the disposal of sputum 
are given in Chapter XLI. 

(2) If linen handkerchiefs are used at all, they must not 
be allowed to get dry after being used, but placed in water to 
which some washing-soda has been added. It is best, however, 
to use paper handkerchiefs or rags which can be burned. 

(3) During coughing the patient must always hold something 
in front of his mouth. 

(4) A fire in the bedroom always helps ventilation, and is 
useful for burning rags, etc. 

(5) Cups, knives, spoons, etc., must be placed in boiling 
water containing some washing-soda before being again used. 

(6) There is no need to sprinkle the floor of the room with 
disinfectants. Washing with soap and water suffices. 

(7) The floor should be uncarpeted except for a rug at the 
bedside. The best plan is to have the floor covered with 
linoleum, washing this daily. The floor should never be dry- 



THE CONSUMPTIVE PATIENT 327 

swept. All articles not washable should be wiped with a damp 
duster. Curtains and other hangings are best discarded. 

(8) The walls should be periodically cleansed, especially 
the part between the floor-level and about a yard above the 
level of the bed. Four methods of cleansing and disinfection 
are commonly adopted ; the help of the officials of the Sanitary 
Authority can be obtained in carrying out one of these : 

(a) The wall-paper if dirty should be stripped off and burnt. 

(b) A solution of chlorinated soda may be brushed on the 

walls. 

(c) Formalin spray (1-50) may be employed. 

(d) The German method of rubbing down the wall with bread- 

crumbs, and then burning the crumbs, may be adopted. 

(9) The patient's room should be carefully chosen, so as 
to be convenient for nursing, and to enable the patient to get 
into the garden whenever practicable. 

(10) The ventilation of the room should be specially studied. 
As a rule, the window and the door should both be kept wide 
open, and generally — by means of screens or otherwise — this 
can be arranged without leaving the patient in a disagreeable 
current of air. If the bedroom has two windows, there is no 
difficulty in securing the perflation of air which is desirable. 
The question of open doors and windows must be decided in 
each case according to circumstances. Gradually the amount 
of fresh air should be increased ; and a sanatorium-treated 
patient will seldom wish to go back to the imperfect ventilation 
which passes muster in most households. On the other hand, 
nothing is gained by increasing the discomfort of a dying 
patient. 

(n) The thoughtful patient will save his nurse as much 
trouble as possible. She must have a sufficiency of sleep, 
exercise, and rest, and must not take her meals in the bedroom, 
The patient must further protect her by always placing a hand- 
kerchief in front of his face when coughing. 

The Patient's Occupation. — The preceding scheme of 
action is concerned chiefly with the patient's home-life. It 
has to be borne in mind, however, that during a large part of 
his illness he is still following his occupation. Commonly, 
if a wage-earner, he has drifted from the more to the less 
laborious occupations, and from the ranks of the steady 



328 THE PREVENTION OF TUBERCULOSIS 

wage-earners to the ranks of the casual workers. But in a 
large proportion of cases, the patient for a year, or even for 
many years, keeps at his work in the factory, workshop, shop, 
or office. As a rule, it is better that he should do so, than that 
in consequence of vague advice " to get a lighter job in the 
open air " he should drift into a condition of unemployment, 
he and his family suffering in consequence from ill-nutrition. 
If there is a definite prospect of more suitable work, it should 
be taken ; but it is of little use, for instance, to advise a clerk 
to become a farm labourer or even a market gardener, unless 
he is unusually strong and the disease is very early. 

Assuming that the patient must keep to his present indoor 
occupation, what advice should be given ? It should first of 
all be urged upon him to come into a sanatorium for a month 
to receive the short course of treatment and teaching which 
is described on p. 349. If he continues his occupation after 
a month thus well spent, he is much more likely to do so without 
danger to others, and with a prospect by careful living of pro- 
longed work, than would otherwise have been possible for him. 

The further advice needed consists chiefly in the avoidance 
of over-fatigue and of the inhalation of dust, and the proper 
use of his spit -bottle. This can be used judiciously, so as not 
to attract attention. In his home-life the ex-patient has the 
opportunity of counteracting to a large extent the influence 
of an unfavourable occupation. He can sleep in the open air, 
take judicious rest, and in other ways, so far as his means permit, 
follow the regime, the principles of which he has learnt while in 
a sanatorium. 

The Patient in relation to the Sanitary Authority. — 
If compulsory notification of phthisis is in force in the town in 
which the patient lives, the doctor in attendance is required to 
notify the patient's illness to the medical officer of health. If 
such notification is invited under a voluntary system, the patient 
has it within his choice to prevent such notification. By so 
doing he will be acting unwisely in his own as well as in the 
public interest. This somewhat bold statement needs perhaps 
elaboration and proof, which it is not difficult to supply. In 
the first place, it can be made clear that the patient will suffer 
no disability by having his case notified. Thus the statement 
that " as soon as they made known that a man was a victim 



THE CONSUMPTIVE PATIENT 329 

to the disease they advertised him as a dangerous person, and 
the public would continue to believe that," ignores the fact 
that notifications are confidential, that the information does 
not pass beyond the householder, that so long as the patient 
takes reasonable precautions as to his sputum, there is no inter- 
ference with his home-life or his occupation. 

In the absence of grave mal-administration the notion that 
notification will involve any interference with a man's occupa- 
tion may be banished as unfounded. At the same time, it is 
true that, quite irrespective of notification, the public have 
become much more alive to the possibilities of infection in 
phthisis, and have ofttimes taken exaggerated action concerning 
it. The best means for reducing such fears to their proper 
magnitude is to be able to reassure the public that every case 
of phthisis is notified and the proper precautions have been 
taken. 

Secondly, the patient himself benefits from notification so 
far as both his domestic and industrial circumstances are con- 
cerned, (a) Domestically the patient has offered to him any 
disinfection that may be required in the interest of himself and 
his family. For the poor, sputum bottles and paper hand- 
kerchiefs are supplied. Under a well-organised system of 
notification, sanatorium treatment is offered (see p. 347). If any 
sanitary defects are found in the house, these are remedied. 
Damp walls, unventilated staircases, windows that do not open 
top and bottom, all militate against the patient's recovery, and 
may be remedied as the result of an official visit. 

(b) Industrially the patient only benefits indirectly. No 
visits to patients are made at workshops or shops, in any town 
with the administration of which I am acquainted. To make 
such visits would be a foolish mistake. But, quite apart from 
the patient himself, workplaces are visited, and defects dis- 
covered and remedied, the remedy of which might otherwise 
have been greatly delayed. No Sanitary Authority possesses 
a sufficiently large staff immediately to discover all sanitary 
defects. Very few Sanitary Authorities have a staff of sanitary 
inspectors sufficiently large to enable them to visit each house 
and workplace in their district once annually. In the intervals 
of such visits conditions of overcrowding, dirtiness, and dustiness 
may long prevail. These conditions are much more dangerous 



330 THE PREVENTION OF TUBERCULOSIS 

where there is a case of phthisis than elsewhere. The notifica- 
tion of cases of this disease enables houses and workplaces in 
which such visits are particularly important to be visited at 
more frequent intervals, a great gain to the public health being 
thus secured. 

Thirdly, the patient by allowing his case to be notified is 
contributing to the general health of the community. The 
notification of his case may lead not only to the removal of 
insanitary conditions favouring the spread of disease, but also 
to the discovery of other untreated cases in the same household ; 
and by comparison with the official records may lead to the 
discovery of particular workplaces or of particular areas of a 
town in which phthisis is exceptionally rife. 



CHAPTER XLI 
THE PREVENTION OF INDISCRIMINATE EXPECTORATION 

THE proper control of spitting and disposal of the sputum are 
probably the chief problems in the prevention of phthisis. 
They therefore deserve a special chapter, and by this 
means repetition of instructions can be avoided in other chapters. 
The closely allied question of instructions for coughing with 
proper safeguards is considered on p. 326. 

As already seen, consumptive patients may discharge billions 
of tubercle bacilli daily in their expectoration (p. 104). This 
may be dangerous immediately while being scattered as fine 
spray ; or after having become dried and pulverised, it may 
be subsequently suspended in the air and inhaled. 

Indiscriminate spitting is much less dangerous in open places, 
for instance in a road, than in houses, public-houses, or other 
places of public resort, especially if these are dark and over- 
crowded. Dr. H. E. Annett (1902) collected by means of 
sterilised swabs 105 specimens of sputum deposited in the 
streets of Liverpool. Five of these were proved to contain 
virulent tubercle bacilli. Apart, however, from such actual 
deposits of expectoration, it is fairly certain that tubercle 
bacilli can seldom be found in the dust of streets in places 
protected from direct expectoration. The explanation of this is 
not far to seek. Notwithstanding the large amount of indis- 
criminate expectoration in streets, many factors tend to cause 
tubercle bacilli to perish within a limited period. When exposed 
in thin layers, direct sunlight kills them in a few minutes or 
hours and diffuse light in a few days. The cleansing of streets b}' 
rain or by road watering must have a very beneficial effect, both 
in washing the bacilli into the sewers and in preventing their 
dissemination as dust. At the same time expectoration in streets 
is an undoubted source of danger, especially when this expectora- 
tion is carried home on the skirts of ladies' dresses or on boots, etc. 

331 



332 THE PREVENTION OF TUBERCULOSIS 

How should the consumptive patient dispose of his sputum 
indoors and out of doors ? 

Indoor Disposal of Sputum. — The problem indoors is 
easily solved. A special spit-cup must be kept for the patient. 
If the amount of expectoration is not very great, it is a good 
plan to line this spit-cup with butter-paper, and then the 
daily expectoration can be easily emptied down a water-closet 
or slop-closet into the drain. A disinfectant is unnecessary in 
the spit-cup under ordinary circumstances ; but care must be 
exercised to ensure that the outsides of the cup are not fouled, 
and that flies are not allowed access to it. The spit-cup after 
being emptied should be washed out in boiling water containing 
some washing-soda, and subsequently washed again, before being 
used. If the expectoration is abundant and adheres to the 
sides of the spit-cup, it is convenient to render it less adhesive, 
and aid its removal from the spit-cup, by adding some soapy 
disinfectant to it before emptying it down the drain. If there 
is no water-closet system, the sputum should be burned, or if 
this is impracticable it should be boiled. In a sanatorium the 
spit-cups should be cleaned and sterilised with boiling soda 
solution, which may be done in a special apparatus heated 
by coal, gas, or steam. In this way the cleansing is effected 
with less trouble, and sterilisation is rendered certain. Floor- 
spittoons should never be tolerated. After expectoration, the 
patient's mouth is frequently soiled, and a paper handker- 
chief should be employed in wiping it. This should be at once 
burnt, or if this is impracticable it should be placed in the spit- 
cup. Japanese handkerchiefs suitable for this purpose are pur- 
chased by the Brighton Corporation at 5s. a thousand. These 
measure 14 inches square, and are cut into four before distribu- 
tion. The patient should also be carefully trained to hold one 
of these handkerchiefs in front of the mouth while coughing. 

Outdoor Disposal of Sputum. — A pocket spit-bottle is 
required for outdoor use. A very good and simple form consists 
of a wide-mouthed bottle, with a thick rubber stopper. It is 
easily cleansed, not easily broken, and of a convenient size 
for the pocket. Such spit-bottles can be obtained at 4d. to 5d. 
each when a gross are bought ; and both they and the Japanese 
handkerchiefs mentioned above are suitable for gratuitous dis- 
tribution in public health administration. The spit-bottle 



INDISCRIMINATE EXPECTORATION 333 

can be cleansed thoroughly with boiling water containing some 
washing-soda. 

It is well to carry the pocket spit-bottle in an indianibber 
pouch or in a pocket having a detachable washable lining ; 
and a similar bag should be used for soiled paper handkerchiefs. 

The Disposal of Sputum of Patients with Advanced 
Disease. — It is generally recognised that the danger of infection 
is greatest in advanced cases of phthisis. Objection has been 
taken to this view, because the sputum of early cases often 
contains multitudes of tubercle bacilli. Several points, however, 
need to be borne in mind: (a) Patients with early disease spend 
a large part of their day away from home, and much of the 
sputum they expectorate is deposited in the open, (b) Ex- 
pectoration at this stage is much smaller in amount than at 
later stages, (c) The patient is not enfeebled by prolonged 
illness, and he still has the courage and strength to avoid fouling 
his handkerchief or his bed and body linen. There is a further 
reason why the sputum of advanced cases of disease is to be 
particularly feared when they are treated at home. The wife 
or other attendant is exhausted by prolonged nursing, and 
depressed by anxiety and sorrow, and is consequently much 
more liable to be open to infection than at an earlier 
period. 

For these reasons a special importance attaches to the manage- 
ment of the sputum of patients with advanced disease. 

Bedridden patients should never be allowed to keep a hand- 
kerchief under the pillow or in the bed. It should always be 
placed in a cleansable receptacle outside the bed. The patient's 
mouth must be covered with a paper handkerchief or rag while 
coughing, the mouth wiped with the same paper or rag after 
coughing, and the material where practicable at once burnt. 
The attendant's hands should be washed after performing these 
duties. 

Public Regulations as to Spitting. — In recent years great 
advances have been made in the control of indiscriminate ex- 
pectoration. In this country the Glamorgan County Council 
was the first to obtain the consent of the Secretary of State 
for the Home Department to a bye-law regulating spitting in 
public places. As originally drafted, the bye-law ran as 
follows :-*- 



334 THE PREVENTION OF TUBERCULOSIS 

A person shall not spit on the floor of any public carriage, or of any 
church, chapel, public hall, waiting-room, schoolroom, theatre, or shop, 
whether admission thereto be obtained upon payment or not. 

Any person offending against this bye-law shall be liable to a fine not 
exceeding £5. 

The Home Office subsequently decided that the bye-law 
could not properly be made to apply to churches, chapels, 
schools, and shops, and the bye-law being amended in accordance 
with this decision came into operation. A considerable number 
of other Local Authorities have now adopted the same bye-law, 
the one commonly in force running as follows : — 

No person shall spit on the floor, side, or wall of any public carriage, 
or of any public hall, public waiting-room, or place of public entertain- 
ment, whether admission thereto be obtained upon payment or not. 

Any person who shall offend against this bye-law shall be liable for 
each offence to a fine not exceeding forty shillings. 

Local Authorities owning tramways have also passed bye- 
laws forbidding expectoration in them, and prosecutions of 
persons offending against such bye-laws have been success ul. 

The Prevention of Spitting in Public - Houses, etc. — 
In my local experience no difficulty has been experienced in 
securing the fixing on the walls of every bar of each public-house 
in the town of an enamelled iron tablet, size 6f x 4! inches, 
having the following words on it : — 



PREVENTION OF CONSUMPTION 

YOU ARE 

EARNESTLY REQUESTED 

TO ABSTAIN FROM THE 

DANGEROUS HABIT OF 

SPITTING 



The following correspondence took place before the tablets 
were exhibited, and it is reproduced here, as^it may be useful to 
others : — 



INDISCRIMINATE EXPECTORATION 335 

To the Sec, Licensed Victuallers' Association. 
,, Beer Sellers' Association. 

„ Brewers' Association. 

Dear Sir, — I enclose herewith a draft of a circular letter which it is 
proposed to send to each publican in the town. 

It deals with a very important question, the importance of which with 
regard to the public health is becoming more and more realised. 

The likelihood of securing compliance with the suggestions made in 
this circular letter would be greatly increased by your co-operation. 
Would it not be practicable for you to bring the question before your 
Association at their next meeting, with a recommendation that individual 
members of the Association should help in bringing about this desirable 
reform ? 

If you have any suggestions to make as to improving the draft circular, 
1 should be glad to receive them and to give them every consideration. — 
Yours faithfully, 

Medical Officer of Health 



To the Proprietor or Tenant of 

Inn or Hotel. 

Dear Sir, — You will probably have learnt from the public press that 
it is now generally realised that consumption, which is the most fatal of all 
the infectious diseases, is spread by inhaling the dried spit or expectoration 
of patients suffering from this disease. It may not be so well known to you 
that the mortality from consumption among those engaged in public- 
houses is much heavier than that of the general public. Our national 
statistics show that if the deaths from consumption for the average of all 
men aged 25 to 65 engaged in various occupations be represented by 100, 
that of innkeepers and brewers is 140 to 148, and of male inn servants is 
257. 

This excess is doubtless due to the conditions to which those engaged 
in public-houses are exposed, among the chief of which is the frequent 
inhalation of dust derived from the expectoration of consumptives. This 
danger is greatly favoured by (a) the practice of indiscriminate spitting 
in the bars of public-houses, and (b) the common practice of allowing 
such spitting on the floor, sawdust being frequently provided for the 
purpose of receiving it. If expectoration on the floor is to be permitted, 
the spit should be washed up by means of a mop several times a day, 
before it has had time to become dry. Sweeping up of sawdust containing 
it is one of the surest methods of distributing a very dangerous infection 
to others as well as to the sweeper. The spit or expectoration is not a source 
of danger (unless directly inhaled when a patient is coughing) in the wet 
condition. Efforts should be therefore directed towards either causing it 
to be immediately burnt in the fire, or, failing this, kept in a moist condition 
until it can be destroyed. 

It may be further remarked that expectoration indoors is very much 
more dangerous than expectoration out of doors. In the latter case its 



336 THE PREVENTION OF TUBERCULOSIS 

infectious properties are soon destroyed by sunlight. Hence, customers 
may fairly be asked to reserve their spitting for out of doors. 

It is suggested that the accompanying tablet should be put up in the 
bar. Further supplies, which it is hoped will be displayed in every public 
room, may be obtained as desired. It is also strongly urged that no 
sawdust should be used on the floor, and that the sweeping of floors which 
may have been spat upon should be entirely discontinued, and daily 
mopping or washing substituted for it. 

Spittoons have not been mentioned hitherto. If not carefully employed, 
they may increase the danger of infection. The floor around spittoons 
becomes soiled with spit j and, unless the spittoon contains water or other 
fluid and is carefully emptied daily and cleansed with actually boiling 
water, it is a possible source of danger. 

I shall be glad to advise with you further on the subject if you think 
this desirable. If you have any suggestions to make as to practical means 
of carrying out the principle of prompt removal of the infection derived 
from dried spit, you will be conferring a public favour by communicating 
them to me. — I am, Sir, yours obediently, 

Medical Officer of Health 



There is no difficulty in securing the exhibition of similar 
notices in each room of common lodging-houses, etc. Most 
railway companies now exhibit such notices in railway stations 
and in each compartment of railway carriages. 

Should Expectoration in Streets be Forbidden ? — 
When we remember the immense change which has taken place 
in our national habits as to spitting, it will be realised what 
progress has already been made in preventing the spread of 
infection by sputum. Not many decades since nearly every 
home was supplied with spittoons, and spitting into the fire 
or fireplace was common. Now spittoons are almost unknown 
except in public-houses and barbers' shops, and domestic spitting 
seldom occurs. If it does, the person finding it necessary to 
spit retires to a lavatory or water-closet. There is still much 
public nuisance from expectoration deposited on public pave- 
ments and roadways, and there must be carriage of infected 
material from such deposits by means of dress-skirts and boots 
into houses. It would not, however, be wise to ask for regulations 
forbidding outdoor expectoration, even though the operation 
of these was confined to towns, for such regulations would go 
beyond present public opinion, and would be systematically 
evaded. It would, however, be well to regulate outdoor ex- 
pectoration, restricting it to certain defined parts of each street. 



INDISCRIMINATE EXPECTORATION 337 

A bye-law to forbid outdoor expectoration, except over street 
gully-tanks, would do much to educate public opinion and keep 
the streets clean ; and a bye-law which, though less rigid than 
the above, would forbid outdoor expectoration except into 
the channel between the roadway and pathway would be 
beneficial. These bye-laws by calling attention to the need 
of frequent swilling of the street-channels would conduce to 
the public health, by the prevention of dust in general as well 
as in reference to tuberculosis. 



22 



CHAPTER XLII 
THE NOTIFICATION OF PHTHISIS 

UP to the present point we have considered preventive 
measures against phthisis chiefly in their relation to 
the patient and his doctor ; slightly and incidentally, but 
viewed from the same standpoint, the relation of the public 
to the patient and his doctor. It is necessary that this wider 
aspect of preventive measures should now be more fully defined. 

We need not fight over again the battle as to whether the 
conditions favouring infection or infection itself are the more 
important. Both are important, and no hygienist would be 
willing to content himself with removing insanitary areas, im- 
proving the ventilation, lighting, and cleanliness of houses, 
preventing industrial dust, and increasing the nutrition of the 
poor, without at the same time adopting measures against 
indiscriminate expectoration, or without, where practicable, 
removing advanced cases of phthisis from the midst of large 
families, in which they cannot be nursed suitably without risk 
to others. 

The great advantage of having cases of phthisis notified is 
not only that each notification enables personal preventive 
measures to be taken against infection, but also that each case 
becomes the point d'appui for the detection of other hitherto 
unrecognised cases, and for the discovery and removal of in- 
sanitary circumstances and conditions either in domestic or 
industrial life. It converts the patient from a focus of infection 
into a focus of prevention. 

Objections to Notification of Cases 

It is perhaps somewhat belated to consider these, as very 
few now object to systems of voluntary notification and the 
action taken thereon, and there is an increasing volume of 

advocacy of compulsory notification of phthisis. It is, however, 

338 



THE NOTIFICATION OF PHTHISIS 339 

convenient to enumerate briefly the main objections which 
have been urged against notification, as their fallacy is not 
always recognised as clearly as it should be. 

(1) It has been commonly urged that notification of cases is 
of relatively small value, because most of the cases — even in the 
absence of wilful concealment — will have been infectious for 
a long time before being notified, and that therefore attempts 
to destroy infective material derived from the patient can have 
only a partial and limited success. I can see no ground for this 
reasoning. It is agreed that risk of successful infection increases 
with increased dosage, and it is probable that advanced cases are 
usually more bacilliferous, or at least eject more bacilliferous 
sputum than early cases. It is evident, therefore, that at 
whatever stage precaution is taken, it must reduce the dose of 
infectious material and the risk of infection which varies with 
it. But this is really an understatement of the case. The 
healthy occupants of a tuberculous home may be compared 
to a city which is the subject of a protracted siege, in which 
the combined effects of arms, and starvation, and depressing 
emotions are at work. The inhabitants of such a city may 
escape with but little damage if the siege is raised at a com- 
paratively early period ; but they succumb if it is protracted. 
Similarly the healthy members of a tubercle-invaded house- 
hold may be able to withstand infection if precautionary measures 
are begun as soon as the nature of the disease is detected and 
are continued thereafter ; but they eventually fall victims to 
the cumulative infection if a fatalistic inertia is allowed to 
prevail, and no efficient precautions are taken. 

(2) In the past some use has been made of the argument 
that as the tubercle bacillus enjoys a saprophytic existence 
apart from its human host, measures directed solely to prevent- 
ing infection from the patient will be ineffective. The same 
line of answer as to the first objection holds in this case ; and 
the objection involves the assumption, which should be unfounded 
in actual practice, that notification is not intended to be accom- 
panied by measures of disinfection and cleansing directed against 
the bacillus in its exiguous saprophytic environment. 

(3) The objection that equally efficient action against the 
defects found after notification can be taken apart from such 
notification, has already been answered (pp. 321 and 328). 



340 THE PREVENTION OF TUBERCULOSIS 

(4) The risk of interference with the patient's occupation 
has been shown not to exist in practice (p. 329). On this point 
there has been confusion between the possible but unrealised 
evil effect of notification, and the independent fact that the 
public on their own initiative, and apart from notification, 
have occasionally had exaggerated fears as to the risks of work- 
ing with consumptives. 

The Impossible Magnitude of the Task? — (5) It has 
been urged also that as phthisis is, unlike the infectious diseases 
now notifiable, a disease of protracted duration, the carrying 
out of official preventive measures is impracticable, and would, 
if attempted, involve a larger staff than is possessed by any 
local Sanitary Authority. This objection can be tested by 
an estimate of the number of cases of phthisis in an average 
population of 100,000 persons. This will be 380 on the basis 
of the data given in the table on p. 63. If we assume that there 
are five cases of active phthisis, each living a year of life in the 
community in which one annual death from that disease occurs, 
instead of three as assumed in the table, then there will be 633 
cases among 100,000 persons. Many of these cases will need 
no visits from the medical officer of health or his assistant. To 
ensure a quarterly visit to 400 of them, about thirty visits would 
need to be made each week. The number of visits actually 
needed is much reduced by having consultations at the medical 
officer of health's office. By this means the cases not actually 
under a doctor can be kept under supervision with relatively 
little difficulty, especially when the medical officer of health 
is the medium through which sanatorium treatment is secured. 
In a larger population it is simply a question of additional help ; 
but the above figures will show that the amount of help required 
is much less than has been stated. 

Le Secret Medical. — (6) The only valid objection is one 
which, in theory at least, presses hard against a voluntary system 
of notification. It is that, in the absence of a statutory obliga- 
tion, the notifying doctor may be laying himself open to awk- 
ward consequences. This is a real difficulty, and must neces- 
sarily always limit the operation of voluntary notification of 
phthisis to patients of the poorer classes, and particularly to 
those treated in connection with the poor law or with public 
institutions. Among these patients I have found that visits 



THE NOTIFICATION OF PHTHISIS 



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Fig. 37. — Brighton. Showing the parallelism between the number of Con- 
sumptive Patients treated in the Sanatorium, of cases of Consumption 
notified, and of Specimens of suspected Sputum examined 



342 THE PREVENTION OF TUBERCULOSIS 

by the medical officer of health are not unwelcome, and that 
they are grateful for the help they receive in having their rooms 
cleansed and purified, etc. In our local experience in Brighton, 
we have secured in addition, under a voluntary system, the 
notification of a considerable proportion of cases of phthisis 
among persons above the wage-earning classes. This is owing 
partly to the fact that in a relatively small town personal in- 
fluence counts to a greater extent, and partly to the provision 
of sanatorium treatment for the notified cases. This is shown 
clearly in the diagram on preceding page. 

It will be noticed that specimens of sputum were more 
readily sent for examination by doctors when sanatorium 
accommodation became available. It may be added that 
in 1906, when the available beds at the sanatorium were increased 
from 10 to 25, a further marked increase of specimens of sputum 
occurred. The number of cases notified has, I think, approxi- 
mated towards the maximum ; and, in the future, I look rather 
towards earlier notification of cases than to any great increase 
in their number. 

In the light of an experience like the above, it is plain that 
voluntary notification may be practised on a large scale, and 
without involving any such risks as have been feared. My 
advice has always been, when consulted on the point by doctors, 
that they should not notify outside of hospital and dispensary 
practice, without first mentioning their intention to the patient. 
When the confidence of the inhabitants as well as of the family 
doctor has been gained, there is little difficulty in securing 
the notification of a large proportion of the total cases. 

The advantages secured by notification are sufficiently in- 
dicated in the preceding pages and on pp. 321 and 328. Even 
with incomplete notification, a large mass of infection can be 
brought under control, and circumstances conducing to infection 
can be minimised. 

The Growth of Voluntary Notification of Phthisis. — 
Nothing is more remarkable in the history of English public 
health administration than the rapid conversion of the medical 
profession and of the public to the necessity for the notification 
of cases of phthisis. The tubercle bacillus was discovered by 
Koch in 1882, and Cornet's investigations into house-infection 
were published in 1886. Very soon after this, instructions 



THE NOTIFICATION OF PHTHISIS 343 

began to be given to patients at several hospitals and dispen- 
saries, denning the precautionary measures required. As early 
as 1887 and 1888, Dr. James Niven printed and distributed 
to every house in Oldham elementary directions for the pre- 
vention of infection. In 1892, Mr. C. E. Paget prepared for 
the North- Western Branch of the Society of Medical Officers of 
Health a memorandum of instructions in methods of prevention. 
At a meeting of the parent Society of Medical Officers of Health 
on August 4, 1893, the following resolutions were passed unani- 
mously on the motion of the present writer : — 

That the Society of Medical Officers of Health, while accepting the 
view that phthisis is an infective disease, in the prevention of which active 
hygienic measures should be taken, think it premature to recommend the 
compulsory notification of a chronic disease like phthisis. They are of 
opinion that it is incumbent on medical officers of health to take such 
steps as may secure — (a) the voluntary notification of cases of phthisis 
by medical officers of public institutions and such medical practitioners 
as agree that precautionary measures are desirable ; (b) the adoption of 
such precautionary measures, including the disinfection of rooms, as can 
be arranged in conjunction with the family practitioner. For this purpose 
the memorandum prepared by the North- Western Branch of the Society 
of Medical Officers of Health would give an excellent basis of action. 

Towards the end of 1893 a scheme of notification recommended 
by Dr. Niven was adopted by the Oldham Medical Society, 
and by it urged, though unsuccessfully, on the Town Council. 
Had it not been for this failure, the voluntary notirication of 
phthisis would, owing to Dr. Niven' s pioneer action, have been 
much earlier adopted in this country than actually occurred. 
This scheme was published in the Lancet on November 18, 
1893. In 1894 a voluntary system of notification of phthisis 
was begun in New York ; while from 1898 onwards the notifica- 
tion of cases of this disease was made obligatory on doctors 
in that city. 

In England the voluntary notirication of cases of phthisis 
was begun in January 1899 in Brighton, and in September 1899 
in Manchester, and since then a considerable number of other 
towns have adopted it, with very varying success. In the 
following table the extent to which notification has succeeded 
is shown. In Sheffield compulsory notification of phthisis 
has been adopted under a special local Act, and its figures are 
compared with those of other towns in Table LXXVI. It will be 



344 



THE PREVENTION OF TUBERCULOSIS 



noted that the number of cases notified is stated in terms of the 
total deaths from phthisis instead of in terms of population, 
in order to give a more accurate proportion between cases 
notified and total cases (which may be regarded as a constant 
multiple in each town of the number of deaths from phthisis). 



Table LXXVI 

Number of Cases of Phthisis notified in each Town to every ioo Deaths 
from the same Disease 





<* 

on 
00 


10 

ON 

00 


ON 

00 


On 
00 


00 

ON 

00 


On 
On 

00 


1 




ON 






On 


1 


i 


*8 

On 


New York (compul- 
sory notification 
from 1898) . 

Brighton (voluntary 
notification) 

Manchester (volun- 
tary notification) . 

Liverpool (voluntary 
notification) 

Sheffield (voluntary 
notification to 
1904, compulsory 
notification from 
1904) . 


94 


112 


167 


201 


173 


153 
* 
38 

6 


137 

61 

138 

58 


175 

93 
118 

139 
49 


197 

128 
112 
163 

66 


211 

174 
113 
149 

91 


251 

209 
109 
Il6 

154 


265 
179 
142 
150 

152 


202 
126 
149 

155 



Under a voluntary system of notification in Brighton we have 
(December 1906) under observation and being visited at regular 
intervals 667 cases of phthisis, or about four times the annual 
number of deaths from this disease. In other towns than those 
named above the extent to which voluntary notification has 
succeeded varies greatly. In the Metropolitan boroughs dis- 
satisfaction is generally expressed with the results of voluntary 
notification of phthisis, and the adoption of compulsory notifica- 
tion is being urged. 

The Compulsory Notification of Phthisis. — The risks 
of notification to the patient's pecuniary or social welfare have 
already been shown to be merely imaginary under a properly 
administered system. The information is confidential, and 
for an officer of a Local Authority to use it to the detriment 
of the patient would be likely to imply serious consequences 
to himself. I have never heard of any such instance of improper 



THE NOTIFICATION OF PHTHISIS 345 

use of the information furnished by notification. The great 
advantage of compulsory notification is that it relieves the 
notifying doctor of any fear that he is improperly revealing 
confidential information. He is merely fulfilling his statutory 
obligation. This is a great gain, and usually must conduce 
to more complete and often to earlier notification of cases, and 
consequent earlier adoption of complete preventive measures. 
The experience of New York, however (Table LXXVL), 
in which city the number of cases notified compulsorily was less 
for a couple of years than it had been under the previous system 
of voluntary notification appears to indicate that compulsion 
may occasionally carry with it some factor tending to depress 
the number of notifications. Sheffield under the guidance 
of Dr. Robertson was the first town to adopt the compulsory 
notification of phthisis, under a local Act, which came into force 
in January 1904. Sec. 45 of the Act dealing with this subject 
is as follows : — 

SEC. 45, SHEFFIELD CORPORATION ACT, 1903 

(1) (a) Every registered medical practitioner attending on or called 
in to visit any person within the City shall forthwith on becoming aware 
that such person is suffering from Tuberculosis of the Lung send to the 
Medical Officer of Health a certificate on a form to be supplied to him 
gratuitously by the Corporation, stating the name age sex and place of 
residence and employment or occupation (so far as can be reasonably 
ascertained) of the person so suffering and whether the case occurs in 
his private practice or in his practice as medical officer of any hospital 
public body friendly or other society or institution. 

(b) Any such medical practitioner who fails to give such certificate 
shall be liable on summary conviction to a fine not exceeding forty 
shillings. 

(c) The Corporation shall pay to every such medical practitioner for 
each certificate duly sent by him in accordance with this section a fee of 
two shillings and sixpence if the case occurs in his private practice and 
of one shilling if the case occurs in his practice as medical officer of any 
hospital public body friendly or other society or institution. 

(d) A payment made to any medical practitioner in pursuance of this 
section shall not disqualify that practitioner from serving as a member 
of the Corporation or as a Guardian of a Union situate wholly or partly 
in the City or in any municipal or parochial office. 

(2) (a) Where the Medical Officer of Health certifies that the cleansing 
and disinfecting of any building (including in that term any ship, vessel, 
boat, tent, shed, or similar structure used for human habitation) would 
tend to prevent or check Tuberculosis of the Lung the Town Clerk shall 
give notice in writing to the owner or occupier of such building that the 



346 THE PREVENTION OF TUBERCULOSIS 

same or any part thereof will be cleansed and disinfected by the Corpora- 
tion at the cost of the Corporation unless the owner or occupier of such 
building informs the Corporation within 24 hours from the receipt of 
the notice that he will cleanse and disinfect the building or the part 
thereof to the satisfaction of the Medical Officer of Health within the 
time to be fixed in the notice. If within 24 hours from the receipt of 
such notice the owner or occupier of such building has not informed the 
Corporation as afoiesaid or if having so informed the Corporation he 
fails to have the building or the part thereof disinfected as aforesaid 
within the time fixed by the notice the building or the part thereof shall 
be cleansed and disinfected by the officers and at the cost of the Corpora- 
tion under the superintendence of the Medical Officer of Health. Pro- 
vided that any such building or part thereof may without any such notice 
being given as aforesaid but with the consent of the owner or occupier 
be cleansed and disinfected by the officers of and at the cost of the Corpora- 
tion under the superintendence of the Medical Officer of Health. 

(b) For the purpose of carrying into effect the provisions of this sub- 
section the Corporation may by any officer authorised in that behalf who 
shall produce his authority in writing enter on any premises between the 
hours of ten o'clock in the forenoon and six o'clock in the afternoon. 

(c) Every person who shall wilfully obstruct any duly authorised 
officer of the Corporation in carrying out the provision of this sub-section 
shall be liable to a penalty not exceeding forty shillings and if the offence 
is a continuing one to a daily penalty not exceeding twenty shillings. 

(3) (a) The Medical Officer of Health generally empowered by the 
Corporation in that behalf may by notice in writing require the owner 
of any household or other articles books things bedding or clothing which 
have been exposed to the infection of Tuberculosis of the Lung to cause 
the same to be delivered over to an officer of the Corporation for removal 
for the purpose of disinfection and any person who fails to comply with 
such requirement shall be liable on summary conviction to a penalty 
not exceeding five pounds. 

(b) Such articles books things bedding and clothing shall be disinfected 
by the Corporation and shall be brought back and delivered to the owner 
free of charge. 

(4) If any person sustains any damage by reason of the exercise by 
the Corporation of any of the powers of sub-sections (2) and (3) of this 
section in relation to any matter as to which he is not himself in default 
full compensation shall be made to such person by the Corporation and 
the amount of compensation shall be recoverable in and in the case of 
dispute may be settled by a Petty Sessional Court. 

(5) No provisions contained in any general or local Act of Parliament 
relating to infectious disease shall apply to Tuberculosis of the Lung or 
proceedings relating thereto under this section. 

(6) All expenses incurred by the Corporation in carrying into effect 
the provisions of this section shall be chargeable on the District Fund 
and General District Rate. 

(7) The Corporation shall cause to be given public notice of the effect 
of the provisions of this section by advertisement in the local newspapers 



THE NOTIFICATION OF PHTHISIS 347 

and by handbills and shall give formal notice thereof by registered post 
to every medical practitioner in the City and any other registered 
medical practitioner known to be in practice in the City and otherwise 
in such manner as the Corporation think sufficient and this section shall 
come into operation at such time not being less than one month after the 
first publication of such an advertisement as aforesaid as the Corporation 
may fix. 

(8) The provisions of this section shall cease to be in force within 
the City at the expiration of seven years from the date of the passing 
of this Act unless they shall have been continued by Act of Parliament, 
or by Provisional Order made by the Local Government Board and con- 
firmed by Parliament which Order the Local Government Board are 
hereby empowered to make in accordance with the provisions of the 
Public Health Act, 1875. 

(9) The term " Medical Officer of Health" in this section shall mean 
the Medical Officer of Health for the time being of the City or any person 
duly authorised to act temporarily as Medical Officer of Health for the 
City. 



The amount of notification hitherto secured under this 
local Act is, as shown in the preceding table, not materially more 
than in Manchester and Liverpool and less than in Brighton 
under systems of voluntary notification. It would, however, 
be unwise to base on these facts inferences as to the relative 
value of the voluntary and compulsory notifications of phthisis. 
Notification, whether voluntary or compulsory, is but a means 
to an end, and it may be that the circumstances of these com- 
munities including their arrangements for treating the notified 
patients differ so much as to render their statistics of notifica- 
tion almost incomparable. It has to be remembered in the 
first instance that Brighton has a population which is only 
one-fourth that of Sheffield, and from one-fifth to one-sixth of 
that of Manchester or Liverpool. This renders the personal 
supervision of notified cases by the medical officer of health 
relatively easy, and generally helps in smoothing the working 
of the system. 

In the next place, no statistics are at present available as 
to the stage of disease at which cases of phthisis are notified. 
The third consideration is that 

The success of notification, whether voluntary or compulsory, 
depends in the main on the extent to which a Local Authority and 
its officers can be helpful to the notified patients. And herein 
lies, I think, the success of successful voluntary notification. 



348 THE PREVENTION OF TUBERCULOSIS 

Notification is the necessary channel through which the avail- 
able help comes. Although it to some extent anticipates what 
is said in later chapters, the character of this help may be now 
summarised : — 

(i) Paper handkerchiefs and pocket spit-bottles are pro- 
vided whenever indicated. 

(2) When the visits are made at the patient's home, every 
possible assistance is given in securing for the patient any help 
needed. The parochial authorities, the Charity Organisation 
Society, and other voluntary agencies are used as far as practi- 
cable . Where the patients are poor, out-patient letters for the local 
hospital or dispensary are given, in order that the patient may 
not be stinted of cod-liver oil and other remedies. Further- 
more, if any other member of the same family appears to be 
failing in health and a doctor's fees cannot be afforded similar 
letters for the hospital or dispensary are given, the importance 
of early treatment of illness and of the maintenance of health 
being emphasised in every possible way. 

(3) Sanatorium treatment is offered in all cases suitable 
for it, and in actual fact more than half of the total cases at 
present under observation in Brighton have spent at least four 
weeks in the Borough Sanatorium, and have there been taught 
the precautionary measures needed to prevent infection, and 
the personal regime indicated by their illness ; while at the 
same time their families have had a temporary holiday from 
the charge of the patient, the house has been disinfected, and 
the patient has returned with a knowledge of the means to 
avoid re-infecting it. 

The chief reason for the success of voluntary notification 
of phthisis in Brighton has been the provision for the sanatorium 
treatment of notified cases. If the dates in the following table 
be compared with the curves in Fig. 37 the coincidence between 
the provision of increased sanatorium treatment and increased 
notification will be evident. 



Brighton 

Voluntary notification of phthisis begun . . Jan. 1899. 

Four beds reserved at a sanatorium outside 

Brighton ..... Maya 902. 



THE NOTIFICATION OF PHTHISIS 349 

Four beds opened for phthisis at the borough 

isolation hospital .... July 1902. 

The number of beds for phthisis at the isolation 

hospital increased to ten . , . Dec. 1902. 

The number of beds for phthisis at the isolation 

hospital further increased to twenty-five . April 3, 1906. 

At first the patients were admitted for only a month, the 
principle adopted being that of training the patients in personal 
hygiene, and in the general management of their illness, rather 
than of attempt at cure. The wisdom of this plan has been 
fully justified by experience. The majority of patients have 
been found to have extensive lung disease, often with cavitation, 
when admitted to the sanatorium. Such patients commonly 
have several years of life before them, but the experience of other 
sanatoria shows that prolonged treatment of many months, or 
even over a year, is necessary to ensure anything approaching 
to a cure even in cases in earlier stages of the disease. It is 
much more to the public interest to pass a large number of 
patients through the sanatorium and train them thoroughly in 
the hygienic requirements of their disease, than to treat a smaller 
number for a more protracted period. It is furthermore much 
more convenient for the patients, who often find it difficult or 
impossible to leave their families and work for longer than a 
month. Our experience is that advice as to the deposit and 
disposal of sputum given at home is commonly neglected ; and 
that it is very rarely neglected by patients who have been in 
the sanatorium. We welcome re-admissions to the sanatorium 
of patients whose health is again flagging. By this and other 
means, and by quarterly visits at the home of the patient, we 
keep in sympathetic relationship with the patients, and ensure 
the maintenance of precautionary measures against infection. 

Should the Notification of Phthisis be made generally 
Compulsory ? — The preceding facts and considerations will 
prepare the way to the conclusion that at present it would be in- 
expedient, unwise, and of relatively little use to advise the general 
adoption of compulsory notification of phthisis. Public opinion is 
not ripe for this step, and such notification would remain to a large 
extent a dead letter. Local Authorities are not ready to utilise 
the information thus received to the benefit of the patient and of 



350 THE PREVENTION OF TUBERCULOSIS 

the public. I place the two together, because they are sub- 
stantially identical. It would, in my opinion, be premature 
for any community to adopt compulsory notification of phthisis 
which (a) does not possess a sufficient staff of skilled visitors, 
preferably medical men or women, to visit the notified 
cases ; and (b) does not possess sanatorium beds available for 
the treatment and training of consumptive patients. Under 
these circumstances compulsory notification can be made to 
work even in the present state of public opinion to the benefit 
of all concerned ; without such aid, I do not say that consider- 
able good will not be done, but that the good done probably 
will not so far exceed that capable of being done under a 
voluntary system as to justify in most districts the addition at 
present of the element of compulsion. 



CHAPTER XLIII 

THE SANITARY AUTHORITY IN RELATION TO 
PREVENTIVE MEASURES AGAINST PHTHISIS 

THE persons primarily concerned in the management of 
a tuberculous patient are the patient himself and his 
doctor. Happily preventive measures and curative 
measures overlap and to a large extent are identical. Hence 
when this fact is realised, the co-operation of patient and doctor 
in carrying out preventive measures may be confidently expected. 
Very often, however, it is not realised. Patients may be ignorant, 
careless, or indifferent. In the later stages of their illness they 
may be unable, unhelped, to adopt the necessary precautions. 
Many doctors furthermore are too busy to explain the necessary 
instructions as to precautionary measures ; and whatever the 
reason, these instructions are frequently found in actual official 
experience not to have been given until the visit of the medical 
officer of health or his assistant is made, or, when given, not to 
have been carried out. The intervention of the Sanitary 
Authority is necessary, under present conditions, to ensure 
preventive measures being taken to the extent required by the 
necessities of public health. Some parts of the duty of the 
Sanitary Authority in this connection have been already con- 
sidered. Of these the first is to ensure the early diagnosis of the. 
disease ; and for this purpose no Sanitary Authority can be 
regarded as fulfilling its duty which does not provide facilities 
for the 

Free Bacteriological Examination of Sputum. — This 
is already being done in many towns, and should become uni- 
versal. Further details on this point are given on pp. 52 and 
314. Next comes the organisation of arrangements for the 

Notification of Cases. — Whether this should be voluntary 
or compulsory will depend on local needs and possibilities, and 
on the considerations urged in Chapter XLII. 



352 THE PREVENTION OF TUBERCULOSIS 

Bye-laws prohibiting Indiscriminate Expectoration 
form an important official means of preventing infection. The 
extent to which these are at present practicable is indicated 
on p. 334- 

A case of phthisis having been notified, what action follows 
as the result of this notification ? 

(a) Collection of Necessary Information. — The method 
to be employed depends on whether the patient desires sana- 
torium treatment, and whether this is available. In Brighton 
a very high proportion of the cases notified bring the notifica- 
tions with them to the Town Hall, often with a letter from 
their doctor, applying for sanatorium treatment. The patient 
is then interviewed by the medical officer of health, and the 
full particulars indicated on the following inspection card are 
obtained. If the patient does not call at the Town Hall, the 
medical assistant of the medical officer of health visits him 
at home. Owing to patients being at work, or being unwilling 
at the first interview to give as full information as is required, 
a second or even a third visit is occasionally required before the 
complete history of each patient can be obtained. The in- 
formation is written on a stiff four-paged inspection card 8x4 
inches. The first page is as follows : — 

NOTIFICATION OF PHTHISIS 
Reg. No. Sanatorium No. 



Name Age. 

Address 

Date of Notification Doctor 

Recommended for Sanatorium by 

Notes by Doctor 



Date of Admission to. 



Date of Discharge from. 



THE SANITARY AUTHORITY 



353 



Date of Change of Address. 
New Address 



Dates of Visit. 



On the inside second and third pages information under 
the following headings is obtained :— 

Duration and History of Illness 



Places of Residence during- Illness. 



Occupation and Workplaces during last 5 years. 



(a) Wages. 



.(&) Work regular. 



No. and Ages in same 
Family. 


No. in 2nd Family. 


History of Cough or 
Consumption among these. 









Family History. 



Precautions : — 
(1) Card 



(3) Pocket Spittoon. 



(4) Habits as to Spitting. 



,(2) Handkerchiefs. 



2 3 



354 THE PREVENTION OF TUBERCULOSIS 

(5) Other Occupants of same Bedroom 



(6) House. 



Habits as to Food and Drink. 



Further Remarks. 



Likely Sources of Infection :— 

(1) Same House (4) Neighbour. 

(2) Companion.. (5) Workmates 

(3) Public-Houses (6) Others 



The fourth page deals with the sanitary condition of the 
home, especially as to cleanliness and crowding, space being 
left at the bottom for a summary of conclusions as to exposures 
to infection, which along with the statement of likely sources 
of infection at the bottom of p. 3 may lead to further inquiries 
and action. 

Condition of Dwelling-house as to— 

No. of available Dwelling Rooms 



Overcrowding 



rof Walls. 



Cleanliness 



Dampness. 



of Ceilings, 
of Floors_ 



of Bedding, etc. 



THE SANITARY AUTHORITY 355 

Ventilation 

Lighting, especially of Staircase [ 

Size of Yard 

Any Sanitary Defects . 



(a) Duration ^f each Case. 



(b) Latest Exposure to Infection before reputed date of onset. 



(c) Duration of Exposure, etc. 



{d) Previous Exposures. 



The inquiry form may seem to be unnecessarily elaborate, but 
it is the result of long experience in the work ; and it has to be 
remembered that the information often accumulates gradually, 
as our acquaintance with the patient improves. 

(b) Giving of Instructions. — At the first interview with 
the patient the card printed on p. 324 is given, and its contents 
are explained to him verbally. 

At the same interview he is instructed in the methods of 
using paper handkerchiefs and a pocket spit-bottle. 

(c) Disinfection. — The next step is to ensure cleansing or 
disinfection of the patient's room as required. The following 
directions, quoted from a circular prepared by Drs. Niven and 
Newman and myself in 1903 and issued by the National Associa- 
tion for the Prevention of Consumption, may be quoted at this 
point : — 

The phlegm infects everything upon which it falls — handkerchiefs, 
books, papers, linen, floors, carpets, furniture, etc., and when dried and 
broken into dust is then readily inhaled by healthy persons. 

On these facts rests the important question of disinfection. In en- 
deavouring to prevent a consumptive person from spreading the disease, 
two sets of preventive measures are required : — 1st. The removal or de- 
struction of the infective matter disseminated by the patient's phlegm ; 
and, 2nd, the prevention of future dissemination. For the latter purpose 
the main object is not to permit any phlegm or discharge to become dry 



356 THE PREVENTION OF TUBERCULOSIS 

before being destroyed. Before the consumptive person has learned the 
personal precautions which must be taken, and up to the time when he 
has been trained to carry them out carefully, he has probably distributed 
a considerable amount of infective matter. This is especially liable to 
accumulate in a dangerous form at home, where the space is small, and 
light and ventilation are defective. Infective particles will be found in 
greatest abundance on and near the floors, on ledges, and in room-hangings. 
But the personal clothing and bedclothes will also have become infected. 
Hence it is necessary to disinfect the floor, walls, and ceiling of the rooms 
occupied by the patient, as well as the furniture, carpet, bedclothes, etc. 

If personal precautions are taken, the risk of infection is lessened, but 
it is impossible to prevent coughed-up minute drops of phlegm from 
being deposited in a room, and rooms should therefore be cleaned at least 
once in a month, the floors being scrubbed with soft soap, the furniture 
washed, the walls cleaned down with dough. The ceiling should also 
be whitewashed every six months. 

Disinfection of rooms which have been occupied by consumptive 
patients may be secured in various ways, but the following are the practical 
rules which must underlie any methods adopted : — 

i. Gaseous disinfection of rooms, or " fumigation," as it is termed, 
by whatever method it is practised, is inefficient in such cases. 

2. In order to remove and destroy the dried infective discharges, 

the disinfectant must be applied directly to the infected surfaces 
of the room. 

3. The disinfectant may be applied by washing, brushing, or spraying. 

4. Amongst other chemical solutions used for this purpose a solution 

of choride of lime (1 to 2 per cent.) has proved satisfactory and 
efficient. 

5. In view of the well-established fact that the dust from dried 

discharges is infective, emphasis must be laid upon the import- 
ance of thorough and wet cleansing of infected rooms. 

6. Bedding, carpets, curtains, wearing apparel, and all similar articles 

belonging to or used by the patient, which cannot be thoroughly 
washed, should be disinfected in an efficient steam disinfector. 

In Brighton a formalin spray is used for disinfecting rooms. 
The preceding instructions when combined with direct pre- 
cautions during the act of coughing suffice to prevent risk of 
infection. 

(d) Remedy of Sanitary Defects. — It is unnecessary 
to detail the means used for the remedy of overcrowding or 
other sanitary defects found in the consumptive's home, as in 
regard to these the usual procedure of sanitary administration 
will be pursued. Notification has, however, secured their remedy 
earlier than would have been practicable under ordinary condi- 
tions (see also p. 321). 

Nor for a similar reason is it necessary to detail measures 



THE SANITARY AUTHORITY 357 

taken in regard to workplaces, for the removal of dust, the 
prevention of daily dust, and the limewashing of walls, etc. 
Notices against spitting in factories, workshops, etc., such as 
the one given on p. 334, are now exhibited fairly generally. 

(e) Education of the Patient. — The great difficulty is to 
secure that the uneducated patient will adopt the simple pre- 
cautions as to coughing and spitting which are needed to prevent 
infection. Most patients, whatever their class, are uneducated 
in this respect, but some patients acquire more easily than others 
the habit of taking the necessary precautions. My personal 
experience is that very few patients can be trusted to follow 
scrupulously the instructions as to coughing and spitting given 
on the card printed on p. 324, except in the light of the careful 
habits inculcated and the personal benefits received at a sana- 
torium. Hence I consider 

(/) The Provision of Sanatorium Training and 
Treatment as one of the most important duties of a 
Sanitary Authority in regard to phthisis. The details under 
this head are described in Chapter XL VI II. ; but there is no 
difficulty in seeing that a medical officer of health or other 
official who goes with an offer of sanatorium treatment is in 
an infinitely better position for receiving a hearty welcome 
than when he merely asks questions which may be regarded 
as inquisitorial, and gives instructions which to the uninitiated 
may seem foolish. 

(g) The Provision of Medical Treatment for other 
Members of the Patient's Family. — The welcome of the 
visitor is likely to be still more cordial when it is known that 
for suitable cases he has hospital or dispensary tickets, and 
can ensure continuous treatment not only for the patient, but 
also for other members of his household when this is indicated 
(see also pp. 318 and 348). 

(h) Revisits. — In some towns visits to consumptive patients 
are made monthly. In Brighton only a quarterly visit is made, 
and it is probable that more frequent visits would lead to friction. 
In order to prevent removal without the knowledge of the 
medical officer of health, notifications of change of address 
are paid for, thus ensuring in a certain proportion of cases prompt 
disinfection of the vacated rooms. With the same object, a 
fee of sixpence is paid to relieving officers who notify a case of 



358 THE PREVENTION OF TUBERCULOSIS 

phthisis, or who notify the removal of such a patient to the 
infirmary or elsewhere. The cleansing and disinfection of 
vacated rooms before they are occupied by another family is 
one of the most important measures in connection with the 
administrative control of tuberculosis. 

(i) In connection with visits and revisits to the patient, the 
question of helping him in gaining his livelihood under the best 
conditions arises. The subject of the after-care of consumptives 
is discussed in Chapter XLVIII. There will doubtless be great 
future developments under this heading, but at present this 
matter is chiefly one for private enterprise and charity. 



CHAPTER XLIV 
EDUCATION AUTHORITIES AND TUBERCULOSIS 

IN previous chapters stress has repeatedly been laid on the im- 
portance of teaching the laws of health (p. 302), and parti- 
cularly on the necessity of having teachers taught these laws 
with special reference to the prevention of tuberculosis (p. 365). 
The necessity for teaching the patient the means of preventing 
the spread of the disease has been emphasised on pp. 318 and 332. 
The prevention of indiscriminate expectoration, which is dis- 
cussed in Chapter XLL, bears on the same subject. 

In all these particulars school authorities have duties which 
they cannot with propriety continue to ignore. This is true 
for all classes of schools, and not less true for secondary than 
for public elementary schools. The majority of children attend 
the latter, and the following remarks, produced from a paper 
on " The School in Relation to Tuberculosis," contributed by 
me to the International Congress on School Hygiene, August 1907, 
relate chiefly to them. It is convenient to reproduce here the 
remarks as to the amount of open and recognisable tuberculosis 
in schools, as well as those relating to its prevention. 

Happily the Education Committees governing general 
elementary education in this country, although they have 
important specially delegated duties and have co-opted members, 
form part of the local Sanitary Authority, and there is every 
reason why they should actively co-operate to the fullest extent 
in securing the prevention of tuberculosis. The new machinery 
for the medical inspection of scholars will be an invaluable 
means to this end, especially in districts in which notification 
of cases of phthisis to the medical officer of health is in successful 
operation. 

Elementary day - schools may be considered from the 
following standpoints : — (1) Whether tuberculosis is spread in 
them and to what extent ; (2) whether the conditions of life 

=»S9 



360 THE PREVENTION OF TUBERCULOSIS 

and work in such schools tend to bring into activity latent 
tuberculosis ; and (3) as important means for teaching and 
training children so that we may obtain the aid of the next 
generation in the rapid elimination of tuberculosis. 

The Amount of Tuberculosis at School-Ages. — Before 
we can arrive at any definite decision on the first point, it is 
necessary to know how much tuberculosis there is among children 
of school- age. So far as tuberculosis terminating fatally during 
school-life is concerned, the figures of the Registrar-General's 
reports enable this point to be settled with some approxima- 
tion to accuracy for the age-periods 5 to 10 and 10 to 15, 
which may be taken as practically coincident with school-ages. 
Fig. 38 gives the death-rates from pulmonary and from all forms 
of tuberculosis in the aggregate per million living at each age- 
period in the decennium 1891-1900 (Decennial Supplement, 
R.G., Dr. Tatham). The interval between the lower and higher 
space in each column represents the death-rate from all forms 
of tuberculosis, excluding pulmonary tuberculosis. 

It will be noted that at ages under 5 pulmonary tuberculosis 
only supplies about one-ninth ; at ages 5 to 10 less than one- 
third ; and at ages 10 to 15 not much more than one-half 
of the total registered mortality from tuberculosis. At higher 
ages the proportion of pulmonary to total fatal tuberculosis 
becomes greater. 

It will be noted furthermore that at ages 5 to 15 the 
death-rate from pulmonary and from all other forms of tuber- 
culosis in the aggregate is lower than at any other age-period, 
except at ages over 75. It is clear, therefore, that, as a 
fatal disease, tuberculosis is relatively uncommon at school- 
ages. Taking the ages 5 to 15 together, it is the registered 
cause of death each year of only about seven out of every 10,000 
children living, while pulmonary tuberculosis only supplies three 
out of these seven. 

As a means of spread of tuberculosis, pulmonary tuberculosis 
is supreme, all other forms of tuberculosis being almost negligible 
in this respect. How many cases of pulmonary tuberculosis 
are there for every fatal case of this disease ? In adults the 
proportion is usually given as three to one, though this is 
probably too low (see p. 63). If we assume that there are 
constantly as many as ten non-fatal cases for each annual death, 



EDUCATION AUTHORITIES 



361 



then three out of every thousand children at school-ages are 
suffering from pulmonary tuberculosis, on the basis of the 
figures of the last decennial period. 

It does not follow that all these phthisical children are in 
attendance at elementary schools. Many of them doubtless will 
not be. 

Compare this estimate with the actual results of examination 



4000. 




j^sTrrT- 15- io- 25-15 



US- 55- k>5— 75-* 



Fig. 38. — Death-rate per million living in each Age-period from Phthisis (dotted) 
and from other forms of Tuberculosis (lined) 

of children in elementary schools. These are given more fully 
in a paper by Drs. Lecky and Horton of Brighton (1907). I 
need, therefore, only briefly summarise the results. They very 
exhaustively examined 806 children, of whom 491 were attending 
an elementary day-school, 241 in a parochial industrial school, 
and 74 in the workhouse. These children varied in age from 4 
to 17. Only three cases of phthisis were found — one in the 
parochial school, one in the workhouse, and one in the elementary 
school. With these results may be compared the following, 
which are summarised in the same paper. At Dundee, Dr. A. P. 



362 THE PREVENTION OF TUBERCULOSIS 

Low (1905) found no pulmonary tuberculosis in 517 children ; 
at Dunfermline, Dr. Ash (1905) had a similar result in examining 
1371 children. Dr. Mackenzie, in Edinburgh, found fourteen 
cases in 600 children ; Professor Hay, in Aberdeen, three cases in 
600 children ; the Charity Organisation Society results, Edinburgh 
(Canongate schools), give nineteen cases in 1318 children. These 
results vary greatly, and it appears likely that there has been some 
confusion between bronchitis and phthisis in some of the observa- 
tions, a very easy mistake unless a very careful examination is 
made. 

Dr. Greenwood, at Blackburn, found 67 per cent, of phthisis 
in 1028 children referred to him, but these were children whose 
fitness for schools was already in question, and rather confirm 
the view, which is, I think, correct, that a child failing with 
phthisis usually does not remain in school long before his ill- 
health is recognised. 

Omitting the above negative observations, and Dr. Green- 
wood's results, which represent a selected sick population, the 
proportion of children in elementary schools with revealed 
phthisis appears to be 1 in 43 (Edinburgh), 1 in 69 (Edinburgh, 
second series), 1 in 200 (Aberdeen), and 1 in 296 (Brighton). 
Compare these figures with the estimate of 1 in 333 children 
based on the national death-rate, and on the assumption that 
ten non-fatal cases go to every fatal case, I incline to think 
that there is not, on the average, more than 1 in 300 children in 
schools showing revealed or diagnosable phthisis. 

Is Tuberculosis spread in Schools ? — To what extent 
are these children a source of infection ? Probably very little. 
Children seldom expectorate ; and a child with a troublesome 
cough would not be kept long in school. It does not appear 
likely that there is much spread of tuberculosis from scholar 
to scholar in schools. 

Teachers and caretakers are possible sources of infection. 
There do not appear to be trustworthy statistics of the amount 
of phthisis in teachers. Probably it is somewhat more than in 
the general community, and, judging by my own experience, I 
should say that it is more often laryngeal than in the averages 
of consumptives. The medical examination of teachers and of 
caretakers, as well as of scholars, is obviously indicated as a 
precautionary measure. 



EDUCATION AUTHORITIES 363 

The Amount of Latent Tuberculosis in Scholars. — The 
preceding figures deal with revealed tuberculosis. Latent 
tuberculosis is nearly, if not quite, always non-infectious. Such 
latent tuberculosis has, however, important bearings on school 
hygiene. Notwithstanding the small amount of revealed 
tuberculosis among school-children, such children, if they die 
of other diseases, show, in a very high percentage, evidence of 
tuberculosis, especially in the bronchial glands. Thus Naegeli, 
at Zurich, 1 found in autopsies of children aged 1 to 5 that 
17 per cent., and of children aged 5 to 14 that 33 per cent., 
had tuberculous lesions. 

Such latent lesions are undoubtedly very frequent in children. 
I cannot doubt that the true interpretation of these figures, 
showing as they do heavy incidence of tuberculosis before as 
well as during school-life, is that tuberculous infection in children 
is nearly all domestic and not scholastic in origin. 

How to deal with Latent Tuberculosis. — The presence 
of such latent foci is a constant source of danger to the children 
implicated. Although there is at present no statistical evidence 
to that effect, it is almost certain that in the children of adult 
consumptives such lesions are present to a preponderant extent, 
a fact which supplies a valuable indication for preventive treat- 
ment. The children of such parents should be periodically 
examined by the school-doctor, and the card giving the medical 
state of each scholar should have a column for family history of 
consumption, and for entering any cases of this disease that 
have been or may be subsequently notified in the same house- 
hold. The general notification of phthisis to the medical officer 
of health thus forms an essential part of school hygiene. 

The course to be adopted in regard to such children is a part 
of the problem of general public health administration. Two 
plans are open — the removal of the children from their homes 
either temporarily or permanently to homes or schools at the 
seaside or in the country ; or the institutional treatment of the 
consumptive parent. The former plan has been adopted on a 
considerable scale in France and elsewhere, and occasionally is 
the best or the only available line of prophylaxis ; the latter 
plan is the one which has been chiefly employed in England, 

1 Quoted by Dr. H. Mery, Rapports prisentis au Congres International de 
la Tuberculose, Paris, 1905, p. 298. 



364 THE PREVENTION OF TUBERCULOSIS 

not intentionally, but incidentally in the relegation of a very 
large proportion of consumptives among the poor to the work- 
house infirmary and to other institutions. Judging by inter- 
national statistics, action on the latter line is more effective than 
any other. It brings the greatest relief to the family, both from 
privation and from infection. Supplemented by earlier treat- 
ment and training of consumptives in sanatoria, it will effect 
still more good ; and if there is to be a choice of remedies, the 
balance of good lies on the side of measures directed towards 
removing the patient himself rather than of measures for re- 
moving the children from the infected domestic circle. It is 
evident, however, that both remedies are excellent, and that 
each consumptive family will need to be considered on its merits, 
and the most practicable line of action taken. It may be re- 
peated, however, that, given the choice between measures for 
increasing resistance to infection, and measures for diminishing 
or abolishing exposure to protracted infection, the latter must 
always occupy a supreme position. 

HOW TO PREVENT SCHOOLS FROM PROVOKING LATENT TUBER- 
CULOSIS to activity. — Both in regard to the children under 
special suspicion of tuberculosis, and in regard to all other 
children, much can be done to prevent the school from becoming 
a place in which latent tuberculosis is brought into activity. 
Overcrowding is the rule in schools. A larger floor-space 
should be required. Classes are too large, thus straining the 
voice of the teacher, and making him much more prone to tuber- 
culosis. Ventilation is usually very defective ; and the methods 
of cleansing, involving the raising of dust, need reform. These 
are obvious points of hygiene. In school hygiene they are pro- 
minent because of the grossness with which they are neglected. 
In the boarding-schools of the middle and upper classes we are 
familiar with the overwork and over-fatigue due to excessive 
games, as well as with the insufficient sleep to which Dr. Acland 
has drawn attention. In England the children of the great 
majority of the population almost certainly do not suffer from 
over-fatigue due to games ; but there is little doubt that many 
of these suffer from over-fatigue and want of sleep, due to 
domestic and sometimes to industrial demands, and to defective 
domestic arrangements. These factors cannot fail to aid in 
setting ablaze the smouldering fire of latent tuberculosis. In 



EDUCATION AUTHORITIES 365 

each of these particulars, there is much need for detailed medical 
supervision of our schools and scholars, and for the adoption of 
preventive measures, on the lines that have been briefly indicated. 
If these and similar reforms are secured, the school may be 
made a most important centre for the prevention of tuber- 
culosis. I think that the principal measures needed for this end 
may be summarised as follows : — 

1. The medical examination of all children on admission to 

school and periodically afterwards, supplemented as it 
must be to attain its full value by information system- 
atically acquired in regard to the health conditions of 
their homes and all living in them. 

2. The exclusion of children found to have open or revealed 

tuberculosis. 

3. Special care as to the feeding and general hygiene of 

children from tuberculous families, including avoidance 
of fatigue. 

4. The frequent wet cleansing of schools. 

5. The reduction of overcrowding. 

6. The improvement of arrangements for the ventilation and 

warming of schools. 

7. Careful attention to the personal hygiene of all scholars, 

especially in relation to the removal of adenoids and of 
carious teeth. 

8. The periodical examination of caretakers and teachers, 

and the avoidance of excessive strain on the voice of 

the latter, or over-fatigue in general. 
The Formation of Public Opinion on Tuberculosis in 
the Schools. — Public opinion is formed in the schools ; and if 
each teacher and scholar is taught to practise the laws of health, 
a much more rapid decline of tuberculosis can be secured. What 
has been said about the supreme importance of domestic infection 
illustrates this. The inculcation of good habits as to coughing, 
expectoration, and scrupulous domestic cleanliness, and of 
knowledge as to the relative value of foods and the dangers of 
alcoholic drinks, will go far towards making the school a valuable 
aid in preventing tuberculosis. 



CHAPTER XLV 

THE BOARD OF GUARDIANS AND THE PREVENTION OF 

PHTHISIS 

IN previous chapters we have discussed in relation to the 
prevention of phthisis the functions of the doctor, of 
his tuberculous patient, and of the Sanitary Authority and 
the Education Committee as at present constituted in this country. 
One local governing body remains whose present functions in 
this connection are not less important than those of the two 
bodies already mentioned. This is the Board of Guardians, 
whose duties are to relieve the destitute, giving food, lodging, 
and medical aid when required. The importance of such aid 
in preventing phthisis and in helping to diminish the danger 
of its spread is at once evident. The fact that the help given — 
especially the domestic medical aid — is ofttimes belated and 
insufficient (see p. 307) is well known ; while the importance 
of the institutional relief given by Boards of Guardians has 
not been sufficiently realised in the past. Its bearing on the 
past prevalence of phthisis has been fully discussed in Part II. 
If there is one point that I am more desirous of making common 
property than another, it is that in the improved and more 
general institutional treatment of advanced cases of phthisis 
we have the means ready to hand from which the greatest 
quickening of the rate of decline of the death-rate from this 
disease can be expected. 

The Institutional Treatment of Advanced Cases. — 
So long as Boards of Guardians remain a separate local govern- 
ing body and are hemmed in by present regulations in giving 
indoor medical relief, this timely and general treatment cannot 
be obtained. It is to be hoped, however, that ere long sickness 
will be the sole and sufficient condition of prompt and efficient 
medical treatment for all requiring it. This will imply the 
removal of the parochial stigma from treatment in a workhouse 

r-~"e* 366 



THE BOARD OF GUARDIANS 367 

infirmary. The infirmary will, in fact, no longer be an annexe, — 
except perhaps structurally, — of the workhouse. Until this 
reform is secured, the local problem for administrators is to 
secure for cases of phthisis in the workhouse infirmary the most 
abundant and the most efficient use of separate wards consistent 
with present regulations. There is no compulsory power of 
removal or detention in these wards. The best policy is, by 
provision of sufficient and palatable food, by good medical 
attendance and nursing and general comfort, to make the con- 
sumptive patients unwilling to go home. This advice may 
appear to be contrary to the first principles of poor-law adminis- 
tration. It is, however, actually calculated to diminish [pauperism, 
which ought to be the object of every one concerned. The 
return of consumptive patients to small homes, in which due 
precautions are not likely to be taken, is an effective means 
of growing a later crop of consumptive paupers. The general 
conditions of treatment of advanced consumptives in the wards 
of infirmaries do not differ materially from those in sanatoria. 
The wards will, however, in view of the more serious illness 
of the patients, be kept warmer ; lighter and more easily 
masticated food will be required ; and precautions as to the 
coughing and expectoration of the bedridden patients will 
need to be precise and rigidly carried out. Much can be done 
even for advanced patients to increase their comfort and to 
smooth their path during progressively increasing weakness. 

The medical superintendent of the infirmary occasionally 
has to deal with another class of consumptive, who is extremely 
difficult to control. He is not very ill, he has a troublesome 
cough, and is addicted to indiscriminate spitting. He is occasion- 
ally obstreperous, and the temptation then, and even short of 
this if the patient is dirty in his habits, is to relegate him to 
the able-bodied part of the workhouse as a punishment. This 
is obviously unfair to the able-bodied paupers, and some other 
means, such as separate warding, ought to be devised. 

At this stage comes in the difficulty that the patient will 
probably " take his discharge," and leave the institution, going 
back to a common lodging-house, where he will continue to 
disseminate infection. For such patients, — and for such patients 
only in my opinion, — the power of 

Compulsory Removal to and Detention in an Institution 



368 THE PREVENTION OF TUBERCULOSIS 

is indicated. We are much more timid on this subject than 
our cousins in the United States, as shown by the following 
remarks made by Dr. Knopf at a recent Conference of Sanitary 
Officers of the State of New York : — 

New York was the first city in the world which enacted the compulsory 
removal law in regard to tuberculosis. That is to say, if in the opinion 
of the inspector, the physician in charge, or the visiting nurse, the tuber- 
culous patient is a menace to his fellow-men, he is removed to a hospital 
whether he likes it or not. Now you may think that those patients are 
refractory and might not do well in the hospital. Not at all. It is my 
privilege to be on service as attending physician for six months in 
the year at the Riverside Sanatorium for Consumptives, which is 
in charge of the New York City Health Department. Half of these 
patients are there against their will, and you would be surprised what a 
change it makes in their condition to remove them from the dark, dreary 
tenement houses — where they have neither light, air, nor decent food — 
into a clean bed, plenty of air day and night, and give them good food, 
including eggs and milk. We never lock up the eggs. We tell the patients, 
" Go and help yourselves." They can drink all the milk they wish. You 
would be surprised what results we obtain there in spite of the cases 
being, in the majority, far advanced, and in spite of their being forced 
to go there. If they recover, in not a few instances they become better 
men and women. The results as a whole are most satisfactory. Thus I beg 
of you not to be alarmed when you hear the words compulsory removal. 
It is the most humane and scientific way of treating the consumptive 
poor, who are a menace to their neighbours, without food and air, or 
entirely homeless. 

This experience in New York is interesting ; but it would 
be a mistake to conclude that any such practice would be wise 
in this country. Resort to compulsion, if it were thought 
advisable, should undoubtedly be hemmed in by special con- 
ditions, such as special investigation and a magisterial decision. 
There are, however, cases of the nature indicated above, of 
persons lodged in common lodging-houses or in crowded dwell- 
ings who cannot secure proper nursing and attention, and who 
are suffering to an unnecessary extent themselves, and inflicting 
suffering and unnecessary danger on those about them ; persons, 
again, who are already in the infirmary but wish to return to 
the above conditions ; in whose cases there is need of com- 
pulsory removal or detention. In the vast majority of cases 
there is no need for compulsion, and the power to enforce it 
against them is undesirable. For them, the one thing necessary 
is to make the institutional treatment satisfactory to the patient 



THE BOARD OF GUARDIANS 369 

as well as conducive to the public interests. As has appeared 
so often in considering questions relating to phthisis, this means 
of protecting the community is identical with the best treat- 
ment for the patient, whose cure will usually be the more rapid 
and more probable if the circumstances in which he is treated 
are attractive to him. 

Sanatoria and Boards of Guardians. — Liverpool and 
Bradford have been pioneers in providing for the treatment 
of comparatively early cases of phthisis through Boards of 
Guardians. It is to be hoped that other Boards will follow 
their example. It must be noted, however, that when a patient 
becomes ill enough to be a pauper, he is usually suffering from 
well-established or advanced disease, and that the chief medical 
function of the Board of Guardians under present arrange- 
ments is the treatment of patients who are so ill as to be com- 
pletely unable to work. While infirmary treatment involves 
the stigma of pauperism, far more patients will struggle against 
the disease till they are past recovery, in the hope of avoiding 
the workhouse, than will apply for infirmary treatment at a 
stage at which it can have a fair chance of producing 
recovery, and before they have sown widespread infection 
in their environment. At present, therefore, workhouse 
infirmaries cannot usually cover so wide a field as the local 
Sanitary Authority, which may succeed in obtaining patients 
for treatment at a stage before tuberculosis has produced actual 
disablement. The Boards of Guardians have, in fact, the 
accommodation and arrangements for treatment without being 
able to secure the patients at the most favourable time ; the 
Sanitary Authority can secure the patients, but seldom or never 
has the accommodation and arrangements for treating them. 
This inefficient state of things points to the need for finding 
a way of combining the resources and functions of the two 
Authorities in respect to the treatment of the sick. Such a com- 
bined Authority would then be able to carry out the complete 
institutional treatment of this disease among the poor, namely : — 

1. The protracted sanatorium treatment of suitable early cases. 

2. The shorter treatment of cases of longer duration, among 
patients still able to earn their livelihood, with a view to tem- 
porary improvement, and to training in the management of 
their illness (pp. 357 and 391). 

24 



370 THE PREVENTION OF TUBERCULOSIS 

3. The protracted institutional treatment of advanced cases, 
when the home conditions are unfavourable. 

The Home Treatment of Pauper Cases of Phthisis. — 
The Board of Guardians is frequently faced with the problem 
of giving outdoor relief to the family of a consumptive patient, 
to enable medical treatment and nursing of the patient to be 
continued at home. If any general rule is to be followed in 
such cases, it should be to the effect that outdoor relief ought 
never to be given to consumptive patients. Exceptional 
cases may occur, as, for instance, when the household consists 
only of the patient and his wife ; but even then it is usually 
wiser to admit the patient to the infirmary, release the wife 
from the constant and unrelieved stress of nursing, night and 
day, and when necessary give her outdoor relief after her husband 
has been placed in the position of receiving proper medical 
aid in the infirmary. If there are children in the family, under 
the domestic conditions in which those needing parochial aid 
live, such aid ought seldom if ever to be given except on the 
condition that the patient becomes an in - patient at the 
infirmary. In the light of the past history of phthisis in this 
country, and of the important part which has been played by 
these infirmaries in securing the past decline of the death-rate 
from this disease, no other course is justifiable either in the 
public interest or with a view to safeguarding the patient's 
family. 

The Relief of the Consumptive's Family. — The fatigue 
and chronic mal-nutrition in the families of the poor associated 
with the nursing of a consumptive are powerful influences 
favouring the active development of tuberculosis ; and there 
is no doubt that the provision of food, clothing, etc., at the public 
expense, when required, would tend to diminish this risk for 
the patient's family ; and would diminish the risk of relapse in 
patients who have been sent home from a sanatorium after 
favourable treatment. Dr. Niven has specially drawn attention 
to the need for a fund from which assistance can be given to 
households in which the breadwinner is struck down with phthisis 
while the children are too young to earn wages, and recommends 
that this fund should be administered in connection with the 
official scheme of notification. 

This is a problem in which Boards of Guardians and private 



THE BOARD OF GUARDIANS 371 

philanthropy can both bear a part. In my opinion the medical 
officer of health or his subordinate should not have a direct 
share in the administration of such relief ; but he should be 
responsible solely for such relief as can be given by medical 
and sanitary measures. The most efficient means of relieving 
the family, and the means which most effectively removes the 
risk of further cases of tuberculosis, is the provision of satisfactory 
institutional treatment for the patient, the disinfection of the 
home, and the removal of insanitary conditions. At the same 
time the medical officer of health can set in operation both 
official and private charity for the rest of the household when 
the need for these is indicated. 



CHAPTER XLVI 

INSURANCE AND FRIENDLY SOCIETIES IN RELATION 
TO THE PREVENTION OF PHTHISIS 

LIFE insurance and particularly insurance against sickness 
forms one of the most effective means of combating 
tuberculosis. The sick-pay received by a member of a 
friendly society gives him the means of entering a sanatorium, 
and provides his family with food in his absence, assuming 
that he is treated without payment. In Germany the system 
of insurance against sickness has been developed on an enormous 
scale. All wage-earning workmen in Germany have been 
compulsorily insured against sickness, employer and workman 
contributing to provide an annuity to all persons unable to 
support themselves or over seventy years old. " This insurance 
is effected (Bielefeldt, 1901) under the supervision of the Imperial 
Insurance Department, State Insurance Departments, thirty-one 
insurance institutions territorially limited, and nine special club 
institutions of the Invalidity Insurance." These offices and 
institutions have a financial interest in postponing invalidity, 
as contributions cease when invalidity begins. Hence accurate 
investigations of causes of invalidity have been made. The results 
up to 1901 showed that of male workers employed in mining, 
metal works, factories and the building trades who became 
invalided up to the age of 30, more than half suffer from phthisis. 
Of persons engaged in forestry and agriculture, who became 
pensioners at ages 20-25, 350 out of every 1000 pensioners are 
consumptive. Death statistics similarly showed that at ages 
15-60 in the German Empire, out of every 100 deaths 33 were 
due to phthisis. Hence it was evident that one of the most 
important tasks of the officers of the German Workmen's Insur- 
ance was to battle successfully against tuberculosis. Obligatory 
insurance against sickness has been enforced in Germany since 

June 1883 among industrial employees, the sick employee having 

372 



INSURANCE AND FRIENDLY SOCIETIES 373 

the right to free medical attendance and the payment of half 
his wage for thirteen weeks, or in the alternative to free treat- 
ment in a hospital. In January 1891, insurance against chronic 
invalidity and old age was made obligatory ; and six years later 
it was found that out of 60,000 pensions given, 8500 were 
given to consumptives. Hospital treatment has been made 
obligatory in certain cases, and the duration of compulsory treat- 
ment has been extended to twenty-six weeks, a fourth of the 
patient's wages being paid during this period to his family. If the 
patient relinquishes the treatment^without good reasons, and thus 
incurs the risk of becoming a permanent charge on the pension 
funds, the pension may be refused either wholly or partially. 
The extent to which sanatorium treatment has been carried out 
in Germany is set out on p. 254. 

The general system of insurance in Germany has helped to 
reduce the death-rate from tuberculosis in three ways : firstly, 
patients are able to afford treatment earlier than was formerly 
possible ; secondly, the importance of keeping down grants for 
sickness and invalidity has led to assiduous education of con- 
sumptive patients and of the entire German public in the means 
of prevention and cure ; and thirdly, there has been institutional 
treatment on an extended scale, and for a much longer period. 
A very high proportion of consumptives have been treated in 
the general hospitals of Germany both before and since the 
sanatorium treatment was introduced (p. 287). Any measure 
enabling earlier treatment to be secured by patients, and bringing 
home to the general population the importance of hygienic precau- 
tions against this disease, must greatly aid in reducing its amount. 

It is unlikely that any system on the exact pattern of the 
German system will be adopted in this country. The machinery 
is complicated and elaborate ; and, in part at least, a rate- or tax- 
supported system of medical attendance for those needing it, 
on the lines on which " free " education has already been given, 
is probably more in accord with our national trend of social 
evolution and with our special needs. 

Pending any such great national movement as that suggested 
by the action of Germany, how can Insurance Societies and 
particularly Friendly Societies be utilised in the campaign against 
tuberculosis ? 

Insurance Societies do their best to eliminate consumptives 



374 



THE PREVENTION OF TUBERCULOSIS 



from the list of the insured by careful inquiries into family and 
personal history and by physical examination of the candidate. 
That they do not completely succeed is shown by the following 
table, taken from Dr. Muirhead's report on the experience of the 
Scottish Widows' Fund, 1874-94 : — 



Phthisis. — Annual Death- 
rate per 100,000 Males 
living at each group of 
Ages in 


Ages. 


20-25. 


25-35- 


35-45- 


45-55- 


55-65- 


65-75. 


(1) England and Wales, 
1881-90 

(2) Scottish Widows' Fund 
experience, 1874-94 


234 
104 


304 
143 


358 
163 


35i 
115 


292 
117 


182 
115 



The difference between the insured and the general population 
is partly due to the benefits of selection, though average social 
condition has also much to do with it. Mr. Hoffman (1901) 
has discussed whether, especially in connection with the work 
of Industrial Insurance Companies, it would pay to aid those 
insured by providing sanatorium treatment, etc., for them. He 
points out that the financial interest of the companies is limited to 
the increased duration of the policy-life or the increased premium 
income in consequence of prolonged life ; and estimating the 
prolongation of life by sanatorium treatment at five years, and 
taking as the basis of his computation the experience of his 
own insurance company among industrial policyholders, he 
concludes that the additional income secured by prolonged 
life will not provide by increased premiums one-half of the cost 
of treatment. In the present state of matters it cannot be 
expected that private insurance companies should subscribe 
heavily to sanatoria for consumptive persons whose lives are 
insured with them. They undoubtedly will gain not only by 
sanatorium treatment, but also by improved housing, increased 
cleanliness and temperance, the increasing avoidance of pro- 
miscuous spitting, and all the measures of hygiene and education 
now being pushed forward. 

Friendly Societies are more closely concerned than 



INSURANCE AND FRIENDLY SOCIETIES 375 

Insurance Companies in the diminution of phthisis, for they 
give sickness as well as burial benefits. About fourteen millions 
of the population of the United Kingdom belong to such societies, 
and more than a million and a half belong to Trade Unions 
which have sick benefits, etc. Many more belong to slate clubs 
and similar less satisfactory organisations. Mr. J. L. Stead 
has collected the experience of the Ancient Order of Foresters, 
with the results shown in Table VIII. p. 16. 

Some figures collected by Mr. Garland (1905), based on some- 
what scanty data, indicate that the sick pay of consumptive 
members costs three -times as much as (£14 more than) the 
average sick pay to members dying from other causes. The 
Friendly Societies are very deeply concerned in reducing the 
sickness caused by tuberculosis, and even if ultimately they 
do not find it financially advantageous to provide sanatoria 
for workers on their own account, they would benefit greatly 
by active propaganda against tuberculosis, educating their 
members in every possible way, helping in securing the promptest 
diagnosis of disease, and in obtaining better conditions of housing 
and industrial employment for their members. 

An interesting scheme has been launched by the National 
Association for the Establishment and Maintenance of Sanatoria 
for Workers suffering from Tuberculosis. Mr. Garland and 
Dr. T. D. Lister, in a description of the objects of this Association 
and of the sanatorium recently opened in connection with it 
at Benenden, emphasise the educational aspect of this sanatorium. 
By the graduated employment of the patient, they hope to avoid 
the demoralisation which occasionally occurs at the convalescent 
home and at hospital. They evidently intend the Benenden 
Sanatorium to fulfil the functions which the Brighton Sanatorium 
has exemplified since 1902 of being " really a training school 
for the would-be- well." In their own words — 

The palatial building and the liege-halle must give place to the simplest 
home-like institution and organised training for the resumption of wage- 
earning. If possible, the patients in whom the disease may be believed 
to be arrested should be retained in an after-care colony connected with 
the sanatorium. Here full work and wage-earning can be resumed 
gradually, while yet not entirely out of touch with the medical authorities 
of the sanatorium, though not directly under medical control. For the 
success of such a scheme propagandist work among all the friendly, labour, 
and trade societies affiliated to the movement must be continuously 



376 THE PREVENTION OF TUBERCULOSIS 

pursued, and the co-operation of the medical profession in the selection 
of suitable cases must be anxiously sought. The members of all the 
affiliated organisations must be taught the means of recognising early 
consumption as well as the necessity of seeking treatment before being 
completely incapacitated. The importance of the educational value of 
a term of residence in a sanatorium is inversely proportional to the magni- 
ficence of the buildings and surroundings. Every patient must leave a 
working-class sanatorium convinced that there is nothing in the accom- 
modation or in the life which he experienced there which is incapable of 
being copied in his own simple home. If he be of the fortunate majority 
in whom the disease becomes arrested, he must realise how much his 
future will depend upon himself, and how much he can do of good to his 
fellows by inducing them to live the cleanly, sober, busy, regular life of 
a workers' sanatorium. 

If the Association succeeds in training those sent to its 
sanatorium on the lines here indicated it will be doing admirable 
work, with which it is to be hoped that Friendly Societies will 
see the advisability of associating themselves. 

Meanwhile, apart from the provision of sanatorium treat- 
ment, there is much work for Friendly Societies to do in diminish- 
ing the present drain on their resources through tuberculosis. 
They can ascertain and inform the medical officer of health of 
any insanitary circumstances, and particularly of any dusty 
occupations to which their members are exposed. They can 
start a crusade in every workshop and factory against indiscrimin- 
ate expectoration. They can encourage and almost insist on 
any of their members who are losing weight or who have per- 
sistent cough being thoroughly overhauled, and having their 
sputum examined bacteriologically ; and in these and other 
ways they can help to the early recognition of disease, to its 
treatment while curable, and to the prevention of infection. 



CHAPTER XLVII 
DISPENSARIES AND THE PREVENTION OF PHTHISIS 

SO far we have been concerned with the measures which the 
patient himself and his doctor, the different local authorities 
of the community in which the patient lives, and friendly and 
similar societies can take in the prevention of tuberculosis. Dis- 
pensaries and sanatoria may be either municipal or voluntary 
in their organisation, and together they hold a high place in the 
list of measures against this disease. 

The French hygienists have especially developed dispensaries 
and the Germans sanatoria as a means of fighting tuberculosis, 
and the discussion as to their relative utility has been prolonged 
and sometimes heated. Thus Dr. Calmette of Lille, with whose 
name the French dispensary system is especially associated, 
says that the sanatorium cannot be regarded as a means of 
prophylaxis, but only as the one great means of cure. Dr. Savoire 
of Paris, speaking on the same point, minimises the importance of 
sanatoria because these establishments reject more advanced 
cases and only isolate tuberculous patients " at the stage of the 
disease in which they are least dangerous." These and other 
writers claim that dispensaries, on the contrary, are important 
means for combating the spread of the disease. The relative 
value of the two can best be discussed dispassionately after 
the two institutions have been described. 

It is generally agreed that on the Continent Dr. Calmette 
first realised completely the ideal of a dispensary which would 
be self-contained, not only treating the patients medically, 
but watching over their welfare, visiting them at their homes, 
giving them all the necessary hygienic instructions, and providing 
material and aid when needed. His dispensary, as described by 
MM. Courtois-Sufht and Ch. Laubry (1905), consists of a large 
waiting-hall, two consultation rooms, a dark room for laryngo- 
scopy examinations, a laboratory, and an office for the assistant 

377 



378 THE PREVENTION OF TUBERCULOSIS 

investigator. The chief doctor is assisted by a staff of doctors 
and bacteriologists. Their complete medical investigation of 
each case is supplemented by a social inquiry entrusted to a 
special officer, who visits the home, inquires into urgent needs, 
emphasises the hygienic advice already given, and arranges for 
supplying cod-liver oil, antiseptics, spit-cups, and, where needed, 
food. The dispensary is thus a centre of prophylaxis, thanks to 
its educative work, and to the means of disinfection used by it. 
Dr. Calmette estimates the cost of an establishment helping 
ioo families at about 72,000 francs per annum, not including 
the cost of installation. The work of the dispensary does not 
preclude, of course, the recommendation of suitable early cases 
for sanatorium treatment, and the sending of the children of 
tuberculous parents to seaside resorts, etc. 

The work thus described does not differ materially so far as 
the homes of the patients are concerned from that carried out 
under an efficient system of notification of phthisis in England. 
Such a dispensary as described above does not gather to it all 
the patients in a town, and almost certainly not so large a pro- 
portion of their total number as are notified in an English town 
to the medical officer of health under a fairly successful system 
of notification. The preventive measures that can be taken 
by a medical officer of health have a wider sweep than those 
of the dispensary physician or of his domiciliary visitor. Dis- 
infection is better done, sanitary defects can be effectively 
remedied, and removal to a suitable institution of patients 
housed badly for themselves and their families can more easily 
be arranged. The chief point in which the French dispensary 
system appears to be better than the English system of voluntary 
notification is in the giving of material aid. This under the 
English system can be, and is partially in process of being, 
remedied by co-operation with voluntary helpers, the Charity 
Organisation Society, etc. 

Tuberculosis Dispensaries in England. — The out-patient 
departments of certain British hospitals and certain dispensaries 
have for many years past carried on similar work to that of 
the French dispensaries, apart from the home visits. Even 
these have been arranged at Edinburgh in the pioneer work 
of Dr. Philip. The Victoria Dispensary for Consumption was 
founded by him in 1887, and, with the exception of the giving 



DISPENSARIES 379 

of food, etc., to necessitous patients, the method of procedure is 
identical with that of Dr. Calmette's dispensary. Dr. Philip 
(1906) describes the present arrangements of the Victoria 
Dispensary as follows : — 

The Victoria Dispensary, as at present arranged, contains — 

Two consulting rooms, a laryngoscopy room, one large waiting-room, 
two dressing-rooms (male and female), a general office where names are 
entered, a laboratory for bacteriological examinations, a drug and food 
store. 

The dispensary is open thrice weekly for three or four hours. 

The staff consists of — 

1. Four qualified physicians who attend when the dispensary is open 
for the purpose of examining and instructing patients. Three of the 
physicians are honorary. 

2. One of the medical officers receives a salary of £60 a year, and devotes 
a large amount of time to the work. In addition to examining patients 
at the institution, along with the honorary physicians, he pays domiciliary 
visits to the dwellings of patients in co-operation with the trained nurse. 
He makes bacteriological examinations of expectoration and other suspect 
discharges. By arrangement with the city authorities, he notifies all 
cases of tuberculosis which he meets. He advises regarding the disin- 
fection of houses during illness and after the removal or death of the 
patient. He supervises treatment of patients at their own home when 
this is desirable. He selects suitable patients for the sanatorium. In 
co-operation with the city authorities, he drafts the more advanced or 
dying patients to a hospital now dedicated to such cases in the neighbour- 
hood of the city. 

3. A nurse who has been carefully trained in modern open-air methods 
at the Royal Victoria Hospital for Consumption, Edinburgh — the sana- 
torium in connection with the dispensary — visits the homes of the patients. 
She readily wins their confidence by her interest in their welfare. She 
instructs the patients, or their friends (wives, mothers, etc.), both as to 
treatment and prevention. In co-operation with the visiting physician, 
she reports regarding the patient's residence and other conditions according 
to the annexed schedule of inquiry. The reports, when completed, are 
vouched for by the signature of both doctor and nurse. 

Schedule of Inquiry Regarding Dispensary Patients 
No. in Ledger _ Date of Report , 



Name Age 

Address Married or single ? 

Occupation Has patient changed occupation ? 

Able to work full time ? Or part time ? 

If unable, confined to bed ? 

How long ill ? 

Situation of house (area, ground floor, first, etc.) ? 

Number and ages of inmates ? 



380 THE PREVENTION OF TUBERCULOSIS 

Number and description of rooms ? 
General aspect of house (clean, damp, dusty, smelly) ? 
Number of windows ? Can they open ? 

Are they kept open (a) by day ? 

(6) by night ? 
Have they always been kept open ? 
Does patient sleep alone (a) in bed ? 

(6) in room ? 
How is washing of clothes done ? 
How long in present house ? 

If has moved within two years, previous addresses ? 
Have there been illness or deaths in house ? 

(a) In own time ? 

(b) In previous occupancy ? 
Exposed to infection (a) at home ? 

(b) at work ? 

(c) among friends ? 
Present health of other members of household ? 
What precaution taken to disinfect ? 

T. B. in sputum ? 

T. B. in dust of room ? 

General dietary ? Teetotal ? 

General condition (well-to-do, badly off) ? 

Proximate income of household ? 

Assisted by societies, church, friends, rates ? 

Signed Reporter. 

^Medical Officer. 

4. A volunteer Samaritan Committee of ladies, in conference with 
the doctors, take charge of more distressing cases, where, through pro- 
longed illness, the financial conditions have been much reduced. In 
many cases they visit the patients' houses. With the assistance of the 
numerous charitable and parochial organisations which exist in the city, 
they are enabled to adapt the relief necessary to the particular case. 
The members of the Samaritan Committee further occupy themselves 
with the question of suitable employment for tuberculous persons fit for 
some effort, although unable to work an entire day. In some cases they 
arrange likewise for persons who have been discharged from the sana- 
torium. Attention is also paid to the case of school children affected 
with the disease, so as to have their education supervised on more physio- 
logical lines. The operations of the Committee are regulated at fortnightly 
meetings, and a minute of the business is kept. 

5. An officer — a working-man who gives his entire time to the dis- 
pensary — lives on the premises. This man receives and enters the names 
of the patients on the afternoons when the dispensary is open. When 
the dispensary is not formally open, he attends to requests from patients 
or other persons. The officer is conversant with the home and work 
conditions of many of the patients, and is a valuable lieutenant both to 
the doctors and nurse. 



DISPENSARIES 381 

Dr. Philip holds that such a dispensary as the above " should be, 
for every city or district, the uniting point of all other agencies.' ' 
In the strictly medical sense, this is true. The dispensary is 
the receiving-house, the clearing-house for patients. It feeds 
the list of official notifications and it enables official preventive 
measures to be taken. But it does not act — in this country, at 
least — as a complete receiving-house, and is not likely to do so. 
A municipal dispensary, and much less a dispensary under the 
control of private charity, will not draw to itself all the con- 
sumptives needing preventive measures as well as curative 
help, though it may be the largest agent to this end. Many 
consumptives will remain under the medical care of private 
practitioners, of club doctors, of private dispensaries, or in the 
out-patient departments of various public hospitals and dis- 
pensaries. Under a system of notification of phthisis the 
medical officer of health forms the centre from which in a well- 
governed community the various measures against phthisis 
start and are co-ordinated and made complete. He is almost 
certain to know of more cases of phthisis than the physician of 
the dispensary, and he has the further advantage that he can 
secure for each patient the removal of insanitary conditions of 
home and workshop, and the necessary disinfection. He can also 
provide handkerchiefs and spit-bottles ; and we hope shortly 
will be able in very many towns to arrange for sanatorium 
treatment and for the hospital treatment of advanced cases. 
The ideal cannot be better stated than in Dr. Philip's words : — 

It cannot be too strongly emphasised that the strength of such a scheme 
lies especially in its organisation and co-ordination. Each factor is 
doubtless of value. Each department has its own sphere of operations. 
As isolated elements their possibilities are relatively limited. In pro- 
portion as the various departments are intimately connected and co- 
ordinated, they each become more serviceable. The key to complete 
success in the campaign against consumption lies in the harmonious 
co-ordination of well-directed measures. 



CHAPTER XLVIII 

THE R6LE OF SANATORIA IN THE TREATMENT AND 
PREVENTION OF PHTHISIS 

A SANATORIUM, as its derivation indicates, is a place 
for the cure of disease, in the present connection of 
tuberculosis. By Trudeau and others the word is used 
to denote also a hospital or asylum for hopeless cases, in which 
they can be cared for and treated under conditions preventing 
infection to others. There is some convenience in accepting 
this wider meaning of the term, in view of the difficulties likely 
to be encountered in the future in the institutional treatment 
of advanced cases of disease. If these are relegated to a separate 
" hospital," they will probably refuse in many instances to 
enter ; if only to a separate ward of a " sanatorium/' consent 
to institutional treatment is much more likely to be secured. 

It is not difficult to define the respective rdles of sanatoria 
for early cases and for advanced cases of disease. The former 
are primarily concerned with the effective arrest, if not actual 
cure, of the disease ; the latter with the sympathetic care of 
the progressively sick, and with the prevention of infection. 
For I quite agree with Dr. Philip's and the general dictum that 
" there can be no manner of doubt that the far advanced or 
dying cases constitute the greatest source of infection " (see also 
pp. 103 and 257). The functions of the two classes of sanatoria 
overlap, for the effective arrest of disease in the individual 
is an excellent way of stopping infection ; and for this reason, 
if for no other, the sanatorium for early cases is also a means 
of prophylaxis of great importance. Its importance in this 
respect is enhanced by its educational influence. No self- 
respecting or even self-regarding patient, after being trained 
in a good sanatorium, will continue to spit without due pre- 
cautions, and his general life in regard to cleanliness and venti- 
lation is likely still further to reduce any possible risk of 



THE ROLE OF SANATORIA 383 

infection. Hence it is a great mistake to regard sanatoria as 
merely cure-places. They are schools of national importance. 

Objects of Sanatoria for other than Advanced Cases. 
— 1. In early and suitable cases a cure may be expected. 

2. Short of cure in a large number of cases, arrest of disease 
occurs, the patient possibly continuing to have a small amount 
of sputum daily, but being able to resume his work. In a still 
larger number of cases, although the disease is not completely 
arrested, the patient's condition is improved, his sputum dimin- 
ished, he is able to resume his work at least to a modified 
extent, and his working life is much prolonged. 

3. While the patient is in the sanatorium his home is dis- 
infected, his relatives are free from recurring infection and 
have time to recover their full measure of resistance to infection. 

4. On his return home and to his work the patient is much 
less likely than before, even though he continues to have sputum 
containing tubercle bacilli, to be a source of infection to others. 

Before considering these points in further detail, it will be 
well briefly to consider the 

History of the Open-Air Treatment of Phthisis. — It was 
an English village doctor named George Bodington who first 
seriously practised the treatment of this disease by what he 
called " the natural method." He described his treatment 
in the following words (1840) : — 

To live in and breathe freely the open air, without being deterred 
by the wind or weather, is one important and essential remedy in arresting 
its progress. 

The cold is never too severe for the consumptive patient in this climate ; 
the cooler the air which passes into the lungs the greater will be the benefit 
the patient will derive. 

The common hospital in a large town is the most unfit place imagin- 
able for consumptive patients, and the treatment generally employed 
there very inefficient, arising from the inadequacy of the means at com- 
mand. 

Dr. Henry MacCormac of Belfast, writing in 1855, emphasised 
the value of open windows and cold air in the arrest of phthisis ; 
and Sir B. Ward Richardson, writing in 1857, quoted by Dr. 
Kelynack (1904), used the following words : — 

In a cosy room the consumptive is bound never to live, nor in any 
room, indeed, for great lengths of time. So long as he is able to be out 
of doors, he is in his best and safest home. 



384 THE PREVENTION OF TUBERCULOSIS 

Stoves of all kinds, heated pipes, and, in a word, all modes of supplying 
artificial warmth, except that by the radiation from an open fire, are, 
according to the facts which I have been able to collect, injurious. 

If special hospitals for consumptives are to be had, they should be 
as little colonies, situated far away from the thickly populated abodes 
of men, and so arranged that each patient should have a distinct dwelling- 
place for himself. They should be provided with pleasure-grounds of 
great extent, in which the patients who could walk about should pass 
every possible hour in the day ; and with glass-covered walks overhead, 
where the open air could be freely breathed, even if rain were falling. 

Opinion gradually grew in favour of an open-air life for 
consumptives, but the main impetus to systematic sanatorium 
treatment has come from Germany, especially from the methods 
employed by Brehmer at Gorbersdorf and by Walther at 
Nordrach. Brehmer, who first began to write on the subject 
in 1856 and opened his sanatorium in 1859, held that tuber- 
culosis was an infectious disease, and, judging by his experience 
of the population at Gorbersdorf, that high altitude had an 
inhibitory influence against it. Arguing from this experience, 
he inferred that anything protecting one person from becoming 
a victim to tuberculosis must, if properly employed, be able to 
cure another person of the same disease ; and on these lines 
he built up his sanatorium treatment, including in it 

1. Living in the open air under conditions which appear to 
give immunity to tuberculosis. 

2. Ensuring freedom from debilitating influences or any- 
thing likely to cause recrudescence of disease. 

3. Methodical exercises, particularly hill-climbing, when 
the patient's condition permitted it. 

4. An abundant diet, especially comprising fatty food, 
milk, and vegetables. 

5. Constant systematic medical supervision, and various 
hydro-therapeutic measures. 

It is unnecessary to follow the recent history of the evolution 
of sanatorium treatment, or the principles embodied in it. In 
the words of Dr. F. Rufenacht Walters (1905, p. 41) " the essence 
of Brehmer's and Dettweiler's methods is the elimination of 
haphazard treatment and the prescription of absolute repose 
or of various degrees of exercise according to definite medical 
indications.' ' 

Structural Conditions and Arrangements of Sanatoria. 



THE ROLE OF SANATORIA 385 

— A very short summary on this subject must suffice, the reader 
being referred for details to Dr. Walters' exhaustive work on 
Sanatoria, and to Dr. Latham's Essay on the same subject. 
Here we are only concerned with the principles that should 
guide local authorities in the matter, and with advice as to the 
avoidance of unnecessary expense. Sanatorium treatment can 
be carried out successfully in any place where the air is pure, 
though a position sheltered on the north and east is preferable. 
If the soil is drained and has a slope, it is unnecessary to select 
a sandy or other porous soil, though this is preferable when 
accessible. The main desiderata as to the site are that 

1. The air must be free from dust. Hence nearness to 
main roads is inadvisable. 

2. Shelter is desirable to the north and east, and there should 
be sheltered walks in the grounds. 

3. The aspect should be sunny. 

The grounds should have shelters suitable for patients to 
lie out of doors during a greater part of each day, and the walks 
should suffice for graduated exercise. 

The arrangements of bedrooms will vary with the class of 
patient. It is always desirable to have a number of bedrooms 
for single patients, but the exclusive provision of single bed- 
rooms in large institutions supported by charity is in my opinion 
an extravagant use of charitable gifts. My experience is that 
six or even twelve consumptive working-men can be treated 
with success in one ward, small rooms being provided for those 
whose coughs are particularly troublesome. There is the further 
point that in such wards absolutely complete perflation of air 
can be secured ; whereas in separate bedrooms as usually 
arranged in sanatoria, a corridor is needed opening from each 
bedroom door. However well-ventilated is this corridor, it 
does not permit as good cross-ventilation as in a hospital ward 
of which the two opposite walls are outside walls with windows 
between each bed ; and single bedrooms on the plan just men- 
tioned are seldom so light and cheerful as a cross-lighted ward. 
If there is a verandah outside the single bedroom, the defective 
lighting becomes a still greater detriment for acute cases con- 
fined to bed. 

Of other structural arrangements it is only necessary to 
say that they need not be expensive to secure efficient treatment 
25 



386 THE PREVENTION OF TUBERCULOSIS 

of the patient. A linoleum flooring is as sanitary as parquet 
and much cheaper. Ledges and corners for dust should be 
avoided. Furniture should be simple and free from unnecessary 
coverings and hangings. Walls may be covered with a wash- 
able distemper. There is much to be said in favour of these 
in preference to well-painted cement walls, as the latter favour 
the condensation of moisture, and clothes hung in the room 
are on humid days cold and damp. Walls and floor and furni- 
ture should be cleansed daily with a damp cloth, a broom or 
brush only being permitted under special conditions. 

Unless in a few special instances for particular purposes, 
the cost of construction should be kept down to £200 or £300 
per patient to be accommodated. It can seldom be justifiable to 
spend £800 to £1200 per bed, as has occasionally been done. 

Principles of Treatment. — Some of the essential points 
have been already indicated, both in dealing with the home treat- 
ment of cases (p. 326) and earlier in this chapter (p. 382). In a 
sanatorium, treatment is more systematic, the patient is removed 
from temptations to depart from the necessary regime, and he 
avoids the risks of catarrhal infection and of mental or bodily 
fatigue or harass which are apt to occur at home. The atmo- 
sphere at the sanatorium is usually purer and freer from dust 
than at his home, and the patient gains the advantages associated 
with a complete change of environment. Specific treatment by 
tuberculin, controlled by opsonic testing, is more easily managed 
at a sanatorium than at home. Hygienic rules can be more 
easily enforced, rest in bed can be controlled in accordance with 
exact observations of the patient's temperature and other 
conditions ; and, where the appetite is deficient, the more or less 
forced feeding which is an important part of sanatorium treatment 
can be efficiently carried out. Although too rapid accumulation 
of fat is undesirable, the indication is to press feeding sufficiently 
to ensure in non-febrile cases a weekly gain of weight of at least 
1 lb., better 2 to 3 lb. (Walters), "until the natural full weight 
is reached, and to ensure this being maintained afterwards." 
The patient can often digest large quantities of meat, even when 
he is feverish. Many feverish patients begin at once to improve 
as soon as they sleep out of doors, or at least stay out during the 
entire day. Complete rest and open-air life give the best prospect 
of reducing the fever of acute phthisis. The regulation of 



THE ROLE OF SANATORIA 387 

amount of exercise is one of the most important duties of 
the sanatorium physician, and it is on this point that the 
superiority of sanatorium over home treatment is most evident. 
As Dr. Latham (1906) remarks : " What the patient learns at 
a sanatorium, and only at a sanatorium, is the fact that fatigue 
kills the majority of consumptives and causes the frequent 
relapses of the disease. The avoidance of fatigue is therefore of 
primary import ance." This leads to the consideration of the 
chief practical objection urged against sanatorium treatment for 
working-men. The problem for them is a serious one. As 
frequently sent out from sanatoriums they are much improved 
in health, but their muscles are soft, and they are unable to 
bear the normal fatigue associated with their daily work. Even 
when able, they are often unwilling. Dr. Walters (1906) may 
be quoted here : — 

It is justly argued that prolonged idleness is apt to foster lazy habits 
and to make the patient less capable of steady work. The remedy for 
this is to substitute other forms of useful occupation as soon as the patients 
are fit for it. Hard manual labour is unsuitable for something like two 
years after the breakdown, but many forms of light work are permissible 
as a rule, such as hoeing, raking, sweeping, pruning, poultry feeding, 
chopping up thin pieces of food, and some of the work in which hand 
machinery is used. The spare time should, however, be chiefly employed 
in education. At Dr. Weicker's sanatorium for artisans in Silesia and 
in some others the patients have regular courses of instruction in short- 
hand, foreign languages, cooking, and the like. Many of the applica- 
tions of science and art to manufacture would also be permissible, such 
as designing, photography, the reproduction of designs, some methods 
of decorating pottery, and some of the applications of microscopy and 
chemistry. A conference of medical men with technical instructors 
in various branches of handicraft would probably bring to light many 
useful occupations open to convalescent consumptives. The chief point 
to bear in mind would be the substitution of delicate for laborious work, 
brains for brawn. That hygienic teaching bearing upon the disease 
itself would be given is taken for granted ; but the addition of suitable 
technical teaching would make the sanatorium a valuable educational 
centre, would add to the happiness and usefulness of the inmates, and 
greatly diminish the difficulty in finding work for discharged patients. 

Short of the change of occupation wisely advocated above, 
wherever practicable, much can be done for the industrial patient 
while in the sanatorium to prepare him to return to his own 
work. On this point I will quote somewhat fully Dr. Kingston 
Fowler's (1906) description of the methods adopted at Frimley, 



388 THE PREVENTION OF TUBERCULOSIS 

the Brompton Hospital Sanatorium, which have been organised 
and successfully carried out under the care of Dr. M. S. Paterson, 
the medical superintendent : — 

Each batch of patients on arrival from the parent hospital at Brompton 
— through which they must all pass — is addressed by the medical super- 
intendent on (i) discipline, (2) fresh air, and (3) feeding. As they have 
already been trained at Brompton for the lesson they have to learn, they 
find but little difficulty in falling in with the more complete open-air 
life followed at Frimley. It was, however, not an easy task to establish 
the tradition of absolute obedience to orders which now prevails ; the 
conviction as to the wisdom of the regulations came to the patients as 
they found themselves steadily improving in health and strength. Now 
everyone cheerfully goes about his appointed exercise or work irrespective 
of the weather, and if told off to roll the lawn for two hours he does it, 
and is not found after five minutes sitting upon the handle of the 
roller. 

As an illustration of the thoroughness of the treatment, so far as " open 
air " is concerned, I may state that the desire of the majority of the 
patients whose bedrooms on the upper floor are without a balcony is 
to be promoted to a room with a balcony, or to one on the ground floor, 
so that they may be able to pull out their beds and sleep in the open 
air. I was told when at Frimley in December 1905 that most of the 
patients at that time slept in the open air when it was not raining. During 
the recent frosty weather the patients were told that they could close 
their windows for an hour whilst they were dressing, but it was found 
that none of the windows were closed. Hats and caps are not worn except 
when walking outside the grounds. The appetite developed by an open- 
air life is surprising ; as most of the staff voluntarily lead the same life, 
they experience a similar increase of appetite. 

Daily Routine. — 6.50 a.m. : Rise and turn down beds and proceed 
according to "Morning Routine." 8.15 a.m.: Breakfast for tables 
i,2,and3. 8.30 a.m. : Breakfast for tables 4, 5, and 6. 9.30^9.55 a.m. : 
Indoor work. 10 a.m. : Outdoor work or exercise. 10.50 a.m. : Lunch. 
11 a.m.: Outdoor work or exercise. 12 to 12.45 p.m.: Absolute rest 
for tables 1, 2, and 3. 12 to 1 p.m. : Absolute rest for tables 4, 5, and 6. 
1 p.m. : Dinner for tables 1, 2, and 3. 1.15 p.m. : Dinner for tables 4, 
5, and 6. 2 to 2.45 p.m. : Absolute rest for tables 1, 2, and 3. 2.15 
to 2.45 p.m. : Absolute rest for tables 4, 5, and 6. 2.45 to 4.35 p.m. : 
Work or exercise in grounds. 5 p.m. : Tea for tables 1, 2, and 3. 5.15 
p.m. : Tea for tables 4, 5, and 6. 5.50 p.m. : Temperatures taken for 
tables 1, 2, and 3. 6.5 p.m. : Temperatures taken for tables 4, 5, and 6. 
6 to 7.45 p.m. : Read papers, write letters, play indoor games, etc. 
7.45 p.m. : Supper for tables 1, 2, and 3. 8 p.m. : Supper for tables 
4, 5, and 6. 8.40 p.m.: Prayers. 8.45 p.m.: Bed. 9.15 p.m.: Lights 
out. 9.30 p.m. : Silence. 

A quarter of an hour is allowed for smoking after each meal. A 
quarter of an hour is allowed before each meal for washing. Patients 
are not allowed indoors except for meals and rest hours until 6 p.m. without 



THE ROLE OF SANATORIA 389 

special permission. Patients may use the concert-hall and reading- 
room from 6 p.m. until prayers. 

Sunday Routine. — The routine is the same, with the following differ- 
ences : There is no work. 9.30 to 10.35 a - m « : Patients walk two miles 
in all weathers. 11 a.m.: Divine service. 12 noon: Rest hour. 
2.30 p.m. : Those patients who have permission may walk outside the 
sanatorium until 4.45 p.m. 

The patient's day is thus so completely occupied that he has little 
leisure for introspection, and I am informed that the only common com- 
plaint is, " We are kept so busy we have no time for anything." 

Graduated Labour. — The new feature which Dr. Paterson has intro- 
duced at Frimley is graduated labour, a feature which appears to me 
to go far to solve the question as to the applicability of sanatorium 
treatment to the poorer classes. County authorities and the public are 
naturally asking : " Are the patients whom you call ' cured ' able to work 
and earn their own living ? " (I deprecate the use of the word " cure/' 
but the public will have it so.) Upon the answer which we are able 
to give to this question the provision of adequate sanatorium accom- 
modation for the poor depends. I believe we can state that the patients 
classed as " arrested " after treatment at Frimley are fit for work. 

The gradation of exercise and labour is as follows : Exercise and 
labour are for two periods daily, each of two hours' duration. (1) Slow 
walking exercise, beginning at two miles a day and gradually increasing 
up to ten miles a day. (2) Picking up fir cones and firewood in the grounds 
and carrying a " half-basket " (weight 1 1 pounds) to the stack. (3) Carrying 
a full basket of firewood and cones (weight 16 pounds). (4) Carrying 
a " half -basket " of gravel or stones from the gravel pit to the place 
where paths are being made or repaired (weight 21 pounds). (5) Carrying 
a basket of gravel or stones, the weight of which is gradually increased 
up to 38 pounds. (6) Rolling the grass or gravel. Sixteen men pull a 
roller weighing 1 5 cwt. (7) Digging ground already broken. (8) Mowing 
grass with a lawn mower. (9) Digging unbroken ground. (10) The same 
as under (9) but for six hours daily instead of four hours — i.e. the hours 
usually spent at rest are spent in labour. 

The indications accepted as evidence of the arrest of the disease are : 
(1) absence of fever; (2) absence of adventitious sounds, except such 
as are indicative of fibrosis ; (3) absence of cough and expectoration ; 
(4) continuous gain of weight or maintenance of the patient's highest 
known weight ; and (5) ability to perform labour incidental to grade 
No. 9 as above. 

The point to which I wish especially to draw attention is that no 
patient is classified on discharge as " arrested " unless for three weeks 
continuously he can pass one or other of the following tests : — 

Test A. — For patients who earn their living by manual labour : To 
be able on an ordinary diet and without rest hours to use a pick and 
shovel of the full size and weight for six hours daily and to maintain 
his health. The shovels and spades are in three sizes, weighing 2, 4, 
and 6 pounds respectively. The picks vary from 3 to 7 pounds in weight. 
Test B. — For patients who do not earn their living by manual labour, 



3Q0 THE PREVENTION OF TUBERCULOSIS 

e.g. clerks, shopmen, or salesmen : To be able on an ordinary diet to 
perform the labour of grade No. 6 or No. 7 for six hours daily for three 
weeks and to maintain his health. These patients are, as a rule, gradually 
brought up to No. 9, and when it is found that they can do this work, 
they are put back to No. 6 or No. 7. The theory is that a man doing 
the work described under No. 9 or No. 10 who on discharge will engage 
in work involving but little bodily exercise, would suffer in health from 
such an abrupt transition. Further experience is, however, necessary 
upon this point. In some cases it is found that patients are unfit for 
No. 9 but that they can be raised to a standard of labour which is equal 
to their ordinary work. These patients are tested before discharge 
on the grade to which they have attained, but they are not, as a rule, 
classified as " arrested." 

The system has been gradually evolved and has not yet been in opera- 
tion for a sufficient time to justify the expression of a final opinion as 
to its value, but there appears to be every reason for anticipating that 
it will prove successful. 

Medical Results of Sanatorium Treatment. — After care- 
ful consideration, I have decided not to utilise any of the many 
published statistics as to sanatorium treatment. So much 
depends upon accurate diagnosis, upon accurate tabulation of 
figures, and upon the lapse of a sufficiently long and uniform 
interval before results are tabulated, that I doubt if many of the 
published figures can be trusted for comparative purposes. 

I am completely convinced that the sanatorium treatment 
is most beneficial to patients, and enables a large proportion of 
them to resume their ordinary life. This is true even for cases 
in which there is consolidation, and occasionally also for cases 
with considerable cavitation of lungs. Although similar cures 
occur apart from sanatorium treatment, clinical experience 
indicates that they are more frequent and occur earlier under 
sanatorium treatment, and I have no doubt that were exactly 
comparable data available, this would be found to be so. As 
Professor v. Ziemssen, quoted by Dr. Walters, says : — 

The possibility of treatment outside a sanatorium with equally good 
results cannot be denied, but it requires much more prolonged rest and 
much more time on the part of the physician, and has by no means so 
certain a result. 

The general results of sanatorium treatment have been well 
summed up by Dr. J. E. Squire as follows : — 

1. It can, he says, be " reasonably expected that of the cases 
of pulmonary tuberculosis which are recognised sufficiently 



THE ROLE OF SANATORIA 391 

early and commence sanatorium treatment without delay, some 
may be cured and return to work in three months." 

2. Three months' treatment being rarely sufficient for the 
stage in which " early " cases are generally admitted to the 
sanatorium, " we are justified in stating that early cases of 
pulmonary tuberculosis may be expected to recover under 
sanatorium treatment if persisted in sufficiently long," but six 
or even twelve months may be required. 

3. There is a further justifiable expectation that by " sana- 
torium treatment, even in acute and somewhat advanced cases, 
arrest may be anticipated provided the patient is able to continue 
the treatment sufficiently long." This generally means at least 
twelve months' treatment and a further period under supervision 
before " cure " can be spoken of. 

Class of Patients suitable for Sanatorium Treatment. — 
The great desire of all physicians at sanatoria is to secure patients 
at an early stage of disease, and their general lament is that this 
desire is not achieved. Not all the cases with physical signs of 
early disease do better than cases of disease of longer standing, 
much depending on the acuteness and febrile reaction of the 
patient. The three months usually allowed for sanatorium 
treatment often does not suffice for cure or arrest of disease. 
The choice of patients in most sanatoria is made from the point 
of view of the individual. Can the disease be arrested or not ? 
is the question asked from this side. It is not identical with the 
view of the public health administrator, whose question in relation 
to sanatoria is, By the sanatorium treatment of what patients, 
and of these for what length of time, can I secure the greatest 
amount of prevention of infection ? This question is sufficiently 
important to be dealt with in a separate chapter. Meanwhile, 
we may add here a few words as to the training of sanatorium 
patients, and as to their after-care. 

The Training of Sanatorium Patients. — An important 
element in the treatment of each patient is that he should know 
the nature of his disease, and should receive exact instructions 
as to the hygienic precautions necessary for aiding his cure, 
for preventing relapse, and for obviating infection. Whatever 
differences of opinion there may be as to the economic gain of 
the sanatorium treatment of wage-earning patients, there can 
be none as to the great gain to the community secured by this 



392 THE PREVENTION OF TUBERCULOSIS 

training. The principles of it are sufficiently obvious, and they 
have been stated on pp. 348 and 357. The following card is 
given to each patient leaving the Brighton Sanatorium : — 



Advice to Patients leaving the Sanatorium 

1. The spit-bottle should always be carried in the pocket, 
and daily washed out with boiling water after emptying its 
contents down the W.C. At home, if the bottle is not used, spit 
into paper or rag, and burn this at once. 

2. Be careful not to cough directly opposite to any other person. 
Always hold a handkerchief to your mouth when coughing. 
Change your handkerchief every day, and put the soiled one into 
water. 

3. In order to maintain a condition of good nourishment, 
take a glass of milk with each of the three chief meals, in addition 
to the ordinary food. 

4. Keep on taking cod liver oil each day until you have no 
cough, unless otherwise ordered by your doctor. 

5. Do not take beer or other alcoholic drinks. Money thus 
spent is wasted. 

6. Keep up the practice of sleeping with your bedroom door 
and window wide open. One of these without the other does not 
suffice. To keep warm, wear plenty of woollen clothes. 

7. It is imperative that you should sleep in a separate bed, 
and if possible have a separate bedroom. 

8. Do not run the risk of inhaling dust if you can avoid it, 
either in the house, or when at work, or in the street. Always 
insist on the " wet cleansing " of rooms, instead of dry dusting or 
sweeping. 

The After-Care of Sanatorium Patients. — The per- 
manence of cure or of arrest of disease depends greatly on the 
training which the patient has received while in the sanatorium, 
and his intelligence and assiduity in living up to it. Ofttimes, 
however intelligent and willing he may be, he cannot live the 
life best calculated to maintain his ground. He is obliged, for 
instance, to return to hard manual labour in a dusty workshop. 
The general considerations applying in this matter are stated on 
p. 327. If alongside these considerations be placed those quoted 



THE ROLE OF SANATORIA 393 

from Dr. Walters on p. 387, we have a statement of possible 
alternatives, of which the resumption of previous work most 
frequently occurs. The difficulty as to subsequent occupation 
is even greater for patients whose expectoration continues, 
often fairly abundant, but who have before them several years in 
which they are still able to work. For these the month's sana- 
torium training mentioned on p. 395 is particularly indicated. 
After this, what is to be done with them ? 

Industrial Colonies have been advocated for them. 
During the patient's stay in the sanatorium itself, something 
may be done in this direction, as indicated on pp. 387-390, and 
the sanatorium may be arranged so as to merge into the industrial 
colony. There is little doubt that a year's life on a farm or farm 
colony after leaving the sanatorium would in many instances 
which now soon relapse mean permanent recovery. There are, 
however, difficulties which prevent one from being very sanguine 
in regard to them. Dr. Jane Walker (1906, p. 365) draws 
attention to three of these : the patients are mostly town-dwellers, 
they are often married men, and they have generally learnt a 
trade, and will not therefore make up their minds to take the 
wages of an agricultural labourer. The subsequent development 
of schemes in this direction will be watched with interest, but it 
cannot be said at present that the establishment of such colonies 
otherwise than by private charity is to be recommended. 



CHAPTER XLIX 

THE INSTITUTIONAL TREATMENT OF PHTHISIS FROM 
THE PUBLIC HEALTH STANDPOINT 

THE subject of this chapter necessarily traverses ground 
already partially covered in previous chapters. It is 
desirable, however, to summarise from the standpoint of 
public health administration the question of the institutional 
treatment of phthisis ; and this chapter may be regarded there- 
fore as an annexe to Chapter XLVIIL, as well as an attempt at 
the practical application of the argument of Part. II. 

Three classes of consumptive patients need to be considered : 
first, those in an early and probably curable stage ; second, those 
who, though showing marked disease, are still able to work 
either continuously or with intervals of inability, and who 
are likely to have several further years of life, whether treated 
or untreated ; and third, advanced cases, unable to work, 
commonly confined to the house except in warm weather, and 
often bedridden. 

Which of these is most dangerous to the public health ? 
Reasons have been already given for the view that the advanced 
cases do most harm ; for not only are they unable to control 
so perfectly the disposal of their more abundant sputum, but 
they require that intimate and protracted personal attention 
which in the ordinary circumstances of domestic life among 
the poor especially favours infection. Against this is to be 
set the fact that the early and the intermediate patients 
have a wider field for scattering infection. The balance of 
evidence is nevertheless strongly against their being the chief 
source of infection. Whatever view be taken on this point, 
evidently the wise course is to ensure the due disposal of ex- 
pectoration by each of the three classes of patient. The training 
of the early patient, when it can be secured, holds good during 
a longer period of infectivity than that of the intermediate or 

394 



INSTITUTIONAL TREATMENT OF PHTHISIS 395 

advanced patient. Hence it should be the rule to ensure the train- 
ing of consumptive patients from the earliest practicable period. 

Sanatorium Training of Early and Intermediate Cases. 
— Early experience of notified cases of phthisis showed me — 
what has been confirmed by later experience — that even when 
I had given definite instructions, both verbally and printed 
(see p. 324), as to care in spitting, on subsequent visits it was not 
infrequently found that these were not being effectually followed. 
Sometimes the instructions had been misunderstood, more 
often they had been neglected. The patient's self-interest as 
well as his conscience needs to be utilised. If he can be taught 
heartily to believe that his own welfare and that of his family 
is favoured by the precautionary measures recommended to 
him, we may usually rely on his co-operation. How to secure 
this educational influence became, then, an important question 
early in my local experience of the notification of phthisis. The 
plan eventually adopted — the success of which in this respect 
has exceeded my anticipations — was the treatment on open- 
air principles of all patients who could be persuaded to consent 
to such treatment. This was carried out in a detached pavilion 
of our hospital for acute infectious diseases which is locally 
known as the sanatorium. The difficulty- in getting patients 
to come into the sanatorium was greatly diminished by the 
fact that only very short terms of treatment were proposed, 
which could in most instances be managed, without the patient 
risking loss of his livelihood. The Fig. on p. 341 shows how 
greatly the number of cases of phthisis voluntarily notified 
in Brighton has increased since sanatorium treatment became 
available. The details of the system adopted in Brighton 
have been regarded with considerable interest, and I therefore 
give here certain fuller particulars which may be of assistance 
in other towns. 

Municipal Sanatorium Training and Treatment at 
Brighton. — The earlier details of our local efforts at sana- 
torium treatment are stated on p. 348 in their relation to the 
notification of cases. Further details will now be given. The 
first point aimed at was to avoid any new capital expenditure 
on buildings ; and in order to do so, to utilise an empty pavilion 
of our present isolation or fever hospital. Epidemics of scarlet 
fever and diphtheria are intermittent, and of enteric fever are 



396 " THE PREVENTION OF TUBERCULOSIS 

very rare ; and yet hospital accommodation in most communities 
is kept ready for the contingency of their occurrence. This 
accommodation it was proposed to utilise for phthisis patients ; 
and there did not seem to be any serious difficulty in doing so, 
as, with the possible exception of an occasional milk outbreak 
of one of the above acute diseases, plans can be made for several 
weeks ahead, and phthisical patients can easily be sent home 
when necessary. Events have proved this forecast correct. 
Not only has it been unnecessary to cease treating consumptives 
at the hospital up to the present time, but we have been able 
to increase our beds for this disease from four to ten and then to 
twenty-five. This increase is in part owing to a charitable bequest 
(the Hedgcock Bequest), which enabled the Town Council to devote 
a yearly income from this source of £600 to £700 to the endow- 
ment of further beds. This fund enabled the number of beds 
for the use of consumptives to be increased from ten to twenty- 
five, including three beds for paying patients, twelve to be 
maintained by the Hedgcock Bequest, and ten provided directly 
by the Town Council. The Town Council provides the entire 
accommodation for these twenty-five patients in its isolation 
hospital. 

The directly municipal patients are usually admitted for a 
month each, and are by preference men and women still able 
to work, and in connection with whom a month's rest, treat- 
ment, and training, can effect the greatest good to the patient 
and to others in preventing infection, both of fellow- workers 
and of family. No charge is made for the admission of these 
patients, who are chiefly labourers, artisans, clerks, etc., and 
their relatives. 

The Hedgcock patients belong to the same classes. They 
must be unable to pay for their own maintenance in the sana- 
torium. Some of them are very advanced, or even dying 
cases, for whom continuance at home is undesirable owing to 
difficulties as to nursing, or because there is a large family 
and much danger of infection. Where practicable, advanced 
cases are treated in separate rooms. It is not, in my opinion, 
necessary to have a separate institution for them ; and the 
objection mentioned on p. 382 is strongly against this. Hedgcock 
patients are kept in the sanatorium for several months or for 
a shorter time, according to individual requirements. 



INSTITUTIONAL TREATMENT OF PHTHISIS 397 

The Method of Using Isolation Hospital Beds 1 

(1) Accommodation available 

The isolation hospital consists of four main pavilions for 
infectious cases — an administrative block, the borough dis- 
infecting station, a laundry, and a small destructor. Three of 
the main hospital pavilions were originally used for scarlet fever, 
diphtheria, and enteric fever, and the fourth for cases needing 
special isolation. 

In the scarlet fever pavilion (two storeys) 68 beds. 
,, diphtheria fever pavilion „ 56 „ 

„ enteric „ „ ; . 22 „ 

,, isolation ,, . 14 „ 

Total 160 ,, 

The population of Brighton estimated to the middle of 1907 
was 129,023, the proportion of beds to population being about 
1 to 800. 



F 


r^" 96' 0* ' 


rGj 







nJ] 


, T^-U 


— ( n J 77 ' ", 


C 

/ i 




K 


L. < 



L^m. 



j=fl 




Fig. 39. — Block Plan of Isolation Hospital. 

A. Discharge Room ; B. Porter's Lodge ; C. Administrative Block ; 
D. IsolationiPavilion ; E. Diphtheria^Pavilion ; F. Phthisis Pavilion ; 
G. Laundry and Disinfecting Station ; H. Scarlet Fever Pavilion ; 
I. J. Phthisis Shelters 

(2) Isolation of the Consumptive Patients from other Diseases 

Visitors from other towns frequently ask the question : " Do 
the phthisical patients run any risk of contracting the infectious 
diseases treated in the hospital ? " The answer is that the 
possibility of the spread of infection depends on the standard 
of administration, and that an experience of six years shows a 

1 The following particulars are taken from a joint paper with Dr. H. C. 
Lecky published in Tuberculosis, June 1907. 



398 THE PREVENTION OF TUBERCULOSIS 

complete absence of such infection. Infection might be spread 
in any of the following ways : (a) By contact between patients ; 
(b) by the carriage of infection by nurses, or (c) by the doctors ; 
(d) by infection from the laundry or kitchen. 

(a) Contact between patients in different pavilions. — It being 
impossible completely to shut off one portion of the grounds 
from another, the keeping of the prescribed bounds depends 
upon the supervision by nurses of children and on the honour 
of patients who have reached years of discretion. Consumptive 
patients are as desirous not to contract another disease as the 
doctor is to prevent it, and patients suffering from diphtheria 
and scarlet fever are under the strictest supervision. In 
practice, therefore, this difficulty scarcely arises, and the erection 
of impassable barriers between areas allotted to the different 
diseases is found to be unnecessary. 

(b) Infection by nurses. — It is customary in isolation hospitals 
for the nurses from the various wards for acute infectious 
diseases to have their meals in a common dining-room in the 
administrative building. In my experience infection has never 
been caused by the adoption of this plan. The experience of 
other isolation hospitals is to the same effect. 

The nurses for the consumptive wards use a separate table 
in the dining-room, and sleep in separate rooms on the first 
floor of the administrative building. All other nurses dine 
at another table in the same room. The nurses for diphtheria 
sleep on the second floor of the administrative building, and 
those for scarlet fever sleep in the dormitories over the scarlet 
fever pavilion with a separate means of access. The nurses 
for different diseases are allowed to go out together, and they 
occasionally use a common sitting-room. 

To enable scarlet fever and diphtheria to be intercommuni- 
cated under the above circumstances by the nurses attending 
these diseases, infection would need to pass through two inter- 
mediaries — a highly improbable event. If infection does not 
spread under these circumstances from scarlet fever to diphtheria, 
or conversely, it is unreasonable to expect that it would spread 
from either of these to consumptive patients, and our confidence 
in this anticipation has been justified by events. 

(c) Infection by the doctor. — The precautions adopted are 
those which every careful practitioner adopts in his everyday 



INSTITUTIONAL TREATMENT OF PHTHISIS 399 

rounds. The consumptive patients are visited first, and overalls 
are used when going into the other wards. 

(d) Infection from the laundry. — The washing from the whole 
hospital is done in one common laundry. Special precautions 
are taken with the soiled linen from the scarlet fever and 
diphtheria pavilions, articles only being sorted after having 
been in soak for a certain time. A definite routine is main- 
tained, so that when the linen has once been washed no soiled 
linen is taken into the laundry during the same week. The 
chances, therefore, of spread of infection in this laundry are 
less than in an ordinary general laundry, and infection, in fact, 
has not occurred. 

(e) Infection from the kitchen. — The food for all the wards is 
distributed from a central kitchen. Every article to be returned 
from the various wards is washed first. No food is ever returned. 

The above summary of our procedure shows that no risk is 
involved in the treatment of consumptives in a well-administered 
hospital, in pavilions properly separated from those for scarlet 
fever and diphtheria. Experience has justified the advice 
given as to the a priori improbability of such spread, for during 
the last six years, in which 730 consumptives have been treated 
for an average period of five weeks for each patient, not a 
single case of an acute infectious disease has occurred among 
these patients. 

(3) The Principles on which Beds in the Sanatorium are 

allocated 

Not every patient notified to be suffering from phthisis is 
offered treatment at the sanatorium. Since the average time 
that the patients can afford to stay is from four to six weeks, 
the main factor determining the admission of patients to other 
hospitals and sanatoria, namely, the possibility of permanent 
benefit or cure, obviously is the factor of least importance in 
deciding as to the admission of patients to our sanatorium. 
The benefit to be derived from the short treatment of patients 
has been summarised on p. 349. From the public standpoint 
it may be summed up in the word education or training : (a) The 
patient is taught that he is in part responsible for his own cure, 
and he is shown the best way of living with this end in view ; 
(6) he is trained so to manage his cough and expectoration that 



4 oo THE PREVENTION OF TUBERCULOSIS 

he is no longer a source of infection to others. These being the 
chief objects at present attempted, each of the following circum- 
stances is taken into account in considering the suitability of 
cases for admission : — 

(a) The age of the patient. — People at the working years of 
life are those who can derive the greatest benefit from the sana- 
torium treatment and training. Children, whose home circum- 
stances are in the hands of others, obviously cannot carry out 
a given line of treatment of their own accord. Furthermore, 
children are seldom sources of infection to others, owing to the 
absence of expectoration. Old people suffering from phthisis 
frequently drift to the workhouse infirmary, and every effort is 
made to facilitate their admission to this institution, though in 
the event of their not coming within the legal limits of the poor 
law they are admitted to the sanatorium if they are likely 
sources of infection. 

(b) The size of the family. — If a family consists of a mother 
and father and several children, and one of the parents has been 
notified, every inducement is offered to get the patient into the 
sanatorium. If, at the same time, the cases of a parent and one 
of the children have been notified, an endeavour is made to get 
them into the sanatorium together. On several occasions two or 
more members of the same family have been treated at the same 
time. If the family consists only of a married man and his wife, 
past middle age, and one of them is notified, there is less necessity 
to urge sanatorium treatment than if other and younger people 
are living with them. 

(c) The occupation. — This is an important factor. Pre- 
ference is always given to consumptives working in factories 
or workshops with a large number of other men or women. 

(d) The stage of the disease. — As mentioned above, this factor 
by itself is of minor importance in determining the suitability 
of notified cases for admission. It is of extreme urgency to 
educate the young adult, especially if he is a bread-winner and 
a parent, both from the standpoint of cure and of prevention 
of infection. Patients with advanced disease are admitted as 
readily as patients having earlier disease, the one condition of 
admission being that the possibilities of infection can be reduced 
by the training of the patient. 

(e) The social position of the patient. — Under our present 



INSTITUTIONAL TREATMENT OF PHTHISIS 401 

system of voluntary notification information is rarely received 
of cases where the family has an income of more than £2 a week. 
Yet, although there is a great difference between the positions 
of a family with an income of 35s. and one with an income of 
25s., the need for sanatorium treatment is almost as urgent 
for the one class as for the other, and no social distinction is 
therefore drawn in admitting patients. The only partial ex- 
ception to this rule is in regard to patients who come within 
the purview of the poor law. If these patients are possibly 
curable they are admitted to the sanatorium. If their disease 
is advanced they are urged to go into the Workhouse Infirmary. 
The arrangements in the thirty beds of that institution reserved 
for phthisis are good, and patients who would otherwise be a 
source of serious domestic infection are well segregated in these 
beds. 

It will thus be seen that the suitability of a patient for 
admission to the sanatorium depends on the answer to the 
following questions : (1) " Will the treatment begun at the 
sanatorium, if subsequently continued, give a reasonable chance 
of a cure ? " (2) " Even if there is no reasonable chance of a 
cure, will the treatment and training diminish and possibly 
prevent the spread of infection to others when the patient leaves 
the sanatorium ? " 

The preceding sketch of local arrangements is given in full 
not as representing an ideal, but as an illustration of what can, 
in many districts, be done without expenditure on new build- 
ings. In other districts, if the isolation hospital accommodation 
is insufficient, new buildings will be required. It is, however, 
most desirable that local authorities should not unnecessarily 
incur heavy capital expenditure, when by possible adaptation 
of already available accommodation the interest on the same 
money might be utilised for the actual treatment of further 
patients. It is possible that in a few years interchange of accom- 
modation for consumptives may be possible between the public 
health and the parochial authorities. If the parochial regula- 
tions could be relaxed for the sick, there is in many workhouse 
infirmaries excellent accommodation for 

Advanced Consumptives who are not Paupers. — The pro- 
vision of accommodation for the patients of this class is the most 
urgent problem in the prevention of tuberculosis. The way 
26 



402 THE PREVENTION OF TUBERCULOSIS 

to this provision in most districts will probably lie through the 
removal of parochial restrictions, and the consequent increase 
of popularity of the consumptive wards of the infirmary. This 
question is dealt with to some extent on p. 394. There can be 
no doubt, as stated in the admirable circular issued by the Local 
Government Board of Scotland (March 1906) on the " Adminis- 
trative Control of Pulmonary Phthisis," that " the isolation of 
such dangerous cases is a primary duty of the local authority." 
The view taken on p. 382 is that these cases may properly 
be treated, though in a separate ward, in the same institution 
as earlier cases of phthisis. The removal of parochial restric- 
tions in respect of the treatment of the sick, it may be hoped, 
will ere long remove the chief difficulty in successfully coping 
with this problem. 

The following estimate by Dr. Rushton Parker gives some 
guidance as to the possible expense involved in the further 
provision of hospital beds for advanced cases of phthisis : — 

As two-thirds (or, strictly, 70 per cent.) of any population usually 
belongs to the working class, and as during the last ten years there have 
been about 42,000 deaths annually from consumption in England and 
Wales, we may assume that 28,000 persons will annually qualify for 
admission into such homes. At those which already exist the applica- 
tions for admission far exceed the vacancies j the duration of stay is 
about six months ; and the annual cost of maintenance is about £6$ 
per bed. We may assume, therefore, that we shall require 14,000 beds, 
at an annual cost of ^1,000,000 a year. About one-sixth of the cases 
would be paupers ; so that one-sixth of the cost would be chargeable 
to the guardians. As it has been calculated that one-eleventh of all 
the pauperism of the country, costing in England and Wales ^11,500,000 
a year (1 900-1 901), arises from consumption, the million pounds a year 
proposed to be so spent should produce much more profitable results 
than the million pounds a year already spent in merely relieving the 
pauperism caused by neglected consumption. 

In every population of 100,000, about 120 die annually of consump- 
tion, of whom 80 require accommodation in a home of 40 beds, at a cost 
of ^2600 a year, roughly equivalent to a penny rate for such population. 



CHAPTER L 

THE PREVENTION OF TUBERCULOSIS DUE TO 
INFECTED FOOD 

THE degree of danger from the flesh of tuberculous animals 
has been already indicated, and it has been seen that 
on present evidence it is much smaller than that from 
milk and its products. Both these dangers might conceivably 
be removed by action along one or other of the following 
lines : — 

i. The extermination of tuberculous cattle and of other 
tuberculous animals used for food. 

2. The prevention — apart from their complete extermina- 
tion — of the use of such animals or their products as human 
food. 

3. The sterilisation of food derived from tuberculous 
animals. 

The first of these lines of action is not within the range 
of immediate practical policy. The Legislature could not be 
expected to undertake the enormous initial expense of the 
destruction of all animals found by means of tuberculin testing 
to be diseased. Short of such wholesale condemnation of 
diseased cattle, more stringent regulations are undoubtedly 
indicated, and there is much room for better enforcement of 
already existing regulations. Thus at the present time it is 
punishable to sell milk derived from cows suffering from tuber- 
culosis of the udder ; but this power is at present in the 
hands of authorities who are usually rural authorities, of whose 
members farmers form a large proportion. If the administra- 
tion of the powers relating to this disease were in the hands of, 
or powers of action in default were given to, larger authorities, 
they would be more likely to be enforced. It is desirable also 
to increase the power of such authorities, enabling them to 

test by means of tuberculin if necessary any cow showing 

403 



4 04 THE PREVENTION OF TUBERCULOSIS 

symptoms suspicious of tuberculosis, whether in the udder or 
not. Further power is needed to prevent the same cow from 
being used for feeding calves or passed on to another farm, 
after its milk has been stopped on the farm where the disease 
was first discovered. At present the farmer can evade the 
results of this discovery, by selling the cow in question. Some 
unobjectionable method of marking such cattle permanently 
would be useful in preventing this traffic. Compulsory slaughter 
is indicated in some cases. Whether limited fractional compen- 
sation should be given in such cases may be left open for con- 
sideration. It is difficult to devise a local scheme for such 
compensation which would work equitably. 

Apart from specific action in respect of tuberculosis in cattle, 
much could be done by improved sanitation in cowsheds to 
diminish the amount of infection from cow to cow. 

Meat from Tuberculous Cattle. — The evidence connect- 
ing tuberculous meat with the possibility of infecting man has 
already been considered (p. 140). In the words of the First 
Royal Commission (par. 22 of their report, April 1895), " any 
person who takes tuberculous matter into the body as food 
incurs some risk of acquiring tuberculous disease/' The cooking 
of meat affords a considerable measure of protection, as all 
except under-done parts would be sufficiently sterilised. With 
uncooked meat, which is often given in the form of pounded 
meat or meat juice to weakly children, there must be considerable 
risk ; and doctors prescribing such meat should give preference 
to meat derived from animals known to have been slaughtered 
at a public abattoir. 

The second Royal Commission on the same subject (1898) 
laid down the following principles in the inspection of the 
tuberculous carcasses of cattle : — 

(a) When there is miliary tuberculosis of> 

both lungs, 
(6) When tuberculous lesions are present on 

the pleura and peritoneum, 
(c) When tuberculous lesions are present in 

the muscular system or in the lymphatic 

glands embedded in or between the 

muscles, 
(i) When tuberculous lesions exist in any 

part of an emaciated carcass, 



The entire carcass and 
• all the organs may 
be seized. 



PREVENTION ARISING FROM FOOD 405 



(a) When the lesions are confined to the lungs 

and the thoracic lymphatic glands, 

(b) When the lesions are confined to the liver, 

(c) When the lesions are confined to the 

pharyngeal lymphatic glands, 

(d) When the lesions are confined to any 

combination of the foregoing, but are 
collectively small in extent, 

They add that 



The carcass, if other- 
wise healthy,shall not 
be condemned, but 
every part of it con- 
taining tuberculous 
lesions shall be seized. 



in view of the greater tendency to generalisation of tuberculosis in the 
pig, we consider that the presence of tubercular deposit, in any degree, 
should involve seizure of the whole carcass and of the organs. In respect 
of foreign dead meat, seizure shall ensue in every case where the pleura 
have been " stripped." 

These rules, where adopted, give a fairly good guarantee 
against the entry of tuberculous meat into the market. They 
are fairly well enforced in all public abattoirs, and possibly 
in a majority of private slaughter-houses in towns ; but in 
rural districts there is no efficient control. It is not even 
obligatory that animals should be slaughtered in a registered 
or licensed slaughter-house ; and when an animal is killed on 
the farm, there is no enactment compelling the submission 
of the carcass to inspection by a competent inspector. Such 
inspectors often do not exist in rural districts. A large amount 
of diseased meat is prepared for the market on unlicensed 
premises in country districts, and is smuggled into towns. The 
one essential for improvement is that no meat should be allowed 
to be exposed for sale, or to be conveyed from place to place 
(except when it is consigned to a clearing house or public abattoir 
for inspection), unless it is stamped in some way, to vouch that 
it has been properly inspected. 

The following extracts from the above report (1898) em- 
phasise as strongly as is needful the evils of the present state 
of things : — 

So long as private slaughter-houses are permitted to exist, so long 
butchers, from use and wont, will continue to use them, and so long 
must inspection be carried on under conditions incompatible with 
efficiency ; besides other disadvantages and risks to health which lie 
beyond the scope of our reference. 

Nor is there anything lacking in thoroughness in the recom- 
mendations of the Royal Commission, which were as follows : — 



406 THE PREVENTION OF TUBERCULOSIS 

We recommend that in all towns and municipal boroughs of England 
and Wales, and in Ireland, powers be conferred on the authorities simila r 
to those conferred on Scottish corporations and municipalities by the 
Burgh Police (Scotland) Act, 1892, viz. : — 

(a) When the local authority in any town or urban district in England 
and Wales and Ireland have provided a public slaughter-house, power 
be conferred on them to declare that no other place within the town 
or borough shall be used for slaughtering, except that a period of three 
years be allowed to the owners for existing registered private slaughter- 
houses to apply their premises to other purposes. The term of three 
years to date, in those places where adequate public slaughter-houses 
already exist, from the public announcement by the local authority that 
the use of such public slaughter-houses is obligatory, or, in those places 
where public slaughter-houses have not been erected, from the public 
announcement by the local authority that tenders for their erection 
have been accepted. 

(b) That local authorities be empowered to require all meat slaughtered 
elsewhere than in a public slaughter-house, and brought into the district 
for sale, to be taken to a place or places where such meat may be in- 
spected, and that local authorities be empowered to make a charge to 
cover the reasonable expenses attendant on such inspection. 

(c) That when a public slaughter-house has been established, inspectors 
shall be engaged to inspect all animals immediately after slaughter, 
and stamp the joints of all carcasses passed as sound. 

We recommend, further, that it shall not be lawful to offer for sale 
the meat of any animal which has not been killed in a duly licensed 
slaughter house. 

Up to the present time, however, no legislation has been 
passed rendering the above practical and important re- 
commendations operative. 

Milk from Tuberculous Cattle. — I cannot better sum- 
marise the dangers and the remedies for the dangers arising 
from tuberculous milk than in the words and recommendations 
of the same Royal Commission (1898). They state their agree- 
ment with the opinion of the previous Royal Commission on 
Tuberculosis, that " no doubt the largest part of the tuberculosis 
which man obtains through his food is by means of milk containing 
tuberculous matter." They then go on to say that " even 
local authorities, which exert themselves to prevent the sale of 
tuberculous meat, are without sufficient powers to prevent the 
sale within their districts of milk drawn from diseased cows." 
It appears clear that the danger of infecting the milk arises 
chiefly, if not solely, when the tuberculosis affects the udder of 
the cow ; but inasmuch as " tuberculosis of the udder can rarely 



PREVENTION ARISING FROM FOOD 407 

be differentiated from other forms of udder disease by the 
ordinary stock owner or dairyman, ... all udder diseases 
should be forthwith notified to the local authority.' ' 

Since the above recommendation was made, tuberculosis of 
the udder has been placed among those diseases of cattle 
where the sale of the milk for human food is forbidden. It is 
unfortunate that the recommendations of the First Royal Com- 
mission have not been also adopted. 

Town dwellers and the local authorities appointed to protect 
their health are in most instances completely impotent in respect 
of public measures against tuberculous milk. On this point the 
report of the same Commission (1898) may be again quoted : — 

It will be seen how futile are the restrictions on the sale of tuberculous 
milk produced within a city in the absence of any safeguard against 
its introduction from without. Clearly there is the most urgent necessity 
for powers being conferred on and exercised by local authorities to make 
periodical inspection of all cows of which the milk is offered for sale within 
their districts. 

They draw attention, furthermore, to the fact already men- 
tioned, that "the spread of tubercle in the udder may be very 
rapid," becoming manifested "between fortnightly inspections 
carried on along with a veterinary surgeon." Notwithstanding 
these facts, they were of opinion, having regard to the extent 
of prevalence of the disease, that " direct action for the elimina- 
tion of all tuberculous cows from dairies should proceed tenta- 
tively." They recommended at once that 

(1) Systematic inspection of the cows in dairies and cowsheds should 
be made by the officers of the local authorities within whose district 
the premises are situated ; (2) that the authorised officers of local author- 
ities within whose districts milk is supplied should have power to inspect 
the cows in any dairy or cowshed, wherever situated ; (3) that power 
should be given to a medical officer of health to suspend the supply of 
milk from any suspected cow for a limited period, pending veterinary 
inspection ; (4) that power should be given to prohibit the sale of milk 
from any cow certified by a veterinary surgeon to be suffering from such 
disease of the udder as in his opinion renders the animal unfit to supply 
milk ; and (5) the provision of a penalty for supplying milk for sale from 
any cow having obvious udder disease. 

The powers enumerated under (2), (3), and (4) remain a dead 
letter in imst urban districts. The nearest approach to them is 
contained in the " model milk clauses" possessed by a few large 



4 o8 THE PREVENTION OF TUBERCULOSIS 

towns in local Acts of Parliament. It is unnecessary to describe 
these clauses in detail ; but subject to tedious regulations they 
enable the veterinary inspector and medical officer of health of 
the town possessing the above powers to inspect the cattle of a 
suspected farm, and if tuberculosis of the udder is found, to 
prohibit the supply of milk to that town from the infected cow. 
There is no power to prohibit its supply elsewhere, and no power 
to prevent the infected cow being sold to another farmer for 
milking purposes. The recommendation of the Royal Com- 
mission on this point is that 

when, under the certificate of a veterinary surgeon, the sale of milk from 
a given cow is prohibited, the local authority should slaughter the 
same, and if on post-mortem examination it appears that the cow was 
not so affected, the local authority should pay compensation to the 
extent of the full value of the cow immediately before slaughter. If, 
on the other hand, the animal be found to be so suffering, the carcase 
should be sold by the authority, and the owner thereof should receive 
the proceeds of the sale. 

This recommendation has not been embodied in legislation. 

In the light of the facts described above it seems clear that 
the enforcement of much more efficient public health administra- 
tion in rural districts than has hitherto been the rule is needed. 

Failing efficient protection of the public against the supply 
of foods which are sometimes contaminated by tubercle bacilli, 
the public still have it within their power to protect themselves 
by refusing to eat uncooked foods derived from the farm. They 
may at the same time, by bringing pressure to bear on the 
purveyors of meat and milk, aid in securing the commercial 
protection which is the subject of the next paragraph. 

Commercial Protection against Bovine Tuberculosis. — 
Apart from the enforcement of public health regulations, public 
protection might be entirely secured under the ordinary 
conditions of commercial life, if the public were willing to 
pay a little more for their milk and milk-products. There 
is in my opinion great scope for commercial enterprise in 
this matter ; and it is not unlikely that the additional ex- 
penditure at first incurred by the enterprising large farmer, in 
eliminating all cattle that reacted to tuberculin, in cleansing 
and disinfecting his sheds, and in giving ample light and air in 
them, would eventually be recouped by the more permanent 



PREVENTION ARISING FROM FOOD 409 

healthiness of his herd. Some doubt may be entertained on 
this point of expense, in view of the large proportion of the cattle 
that would in the first instance need to be eliminated (p. 139), 
and in view of the difficulty in replacing the slaughtered cows 
by others reacting negatively to the tuberculin test. 

The ideal would be that each dairyman should be in a position 
to issue a guarantee to his customers that all the cows from 
which his milk is supplied had been proved to be free from 
tuberculosis by means of the tuberculin test ; and at the same 
time to certify, by means of expert evidence, that all other 
sanitary requirements had been fulfilled. It must be confessed 
that in very few districts is it practicable at the present time to 
purchase milk under an efficient guarantee to the above effect. 

The next alternative is for the dairyman to supply pasteurised 
milk, and this is now largely done on a commercial scale. Often 
it is done to preserve stale milk, and the slight taste of pasteurised 
milk is concealed by mixing the milk with fresh unpasteurised 
milk. This obviously gives little protection to the purchaser. 
Furthermore, the dairyman is only concerned in pasteurising at 
the lowest temperature which will prevent souring of the milk, a 
temperature which, as will be shortly seen, does not suffice to kill 
the tubercle-bacillus. If, therefore, commercial pasteurised milk 
is to be regarded as safe in respect of tuberculosis, the temperature 
and duration of the heating process must be specified. The 
following experimental results throw light on this question : — 

The Thermal Death-point of the Tubercle-Bacillus. — 
In 1887 Sternberg showed that tuberculous expectoration sub- 
jected to temperatures at and above 6o° C. (140 F.) was rendered 
harmless. From this date onwards there has been considerable 
disagreement as to the exact temperature fatal to the tubercle 
bacillus. Theobald Smith in 1897 found that the variable 
results as to the death-point of the tubercle bacillus in milk were 
probably due to the formation of the milk pellicle in which 
bacilli were caught, and thus artificially protected against further 
heat. Russell and Hastings in 1900 found that exposure of tuber- 
culous milk to 6o° C. (140 F.) in a tightly closed commercial 
pasteuriser for ten minutes always destroyed tubercle bacilli, 
while, when milk was heated under conditions allowing a pellicle 
to form, exposure to the same temperature (6o° C.) for consider- 
ably longer times did not kill the bacilli. 



4 io THE PREVENTION OF TUBERCULOSIS 

Domestic Protection against Bovine Tuberculosis. — 
As domestic pasteurisation is not likely to be carried out under 
scientific conditions, it would not be safe to adopt a temperature 
lower than 85 C. (185 F.) in domestic life. Probably, although 
home sterilisers are to be obtained, the safest plan for most 
households is to boil the milk in accordance with the following 
directions given in a pamphlet issued by the National Association 
for the Prevention of Consumption. If these are carried out 
exactly, the " cooked " flavour objected to by many individuals 
will be found to be comparatively slight, and little if any surface 
scum will be formed. 

1. Use a double milk saucepan ; * if, however, this cannot 
be obtained, put the milk into an ordinary covered saucepan 
and place it inside a larger vessel containing water. 

2. Let the water in the outer pan be cold when placed or 
the fire. 

3. Bring the water up to the boil, and maintain it at this 
point for four minutes without removing the lid of the inner milk 
pan. 

4. Cool the milk down quickly by placing the inner pan in 
one or two changes of cold water without removing the lid. 

5. When cooled down, aerate the milk by stirring well with a 
spoon. 

The Protection of other Dairy Products. — Butter and 
cheese may also contain tubercle bacilli. The first is the more 
important, as it bulks more largely in the dietary of children. 
Some of the results as to the presence of tubercle bacilli in butter 
may be exaggerated, owing to possible confusion with other acid- 
fast bacilli. They are, however, sometimes present, and the 
only safe protection is by partially cooking the butter; which, 
however, loses much of its palat ability by this process. 

1 Obtainable from any ironmonger. 



CHAPTER LI 

THE CO-ORDINATION OF MEASURES AGAINST 
TUBERCULOSIS 

REFERRING to the tabular statement on p. 317 it will be 
seen that preventive measures against tuberculosis must 
have regard to the receptivity of the patient, as well as 
to the prevention of infection. The measures against receptivity 
have been almost sufficiently indicated in previous chapters. 
Every improvement in cleanliness and ventilation, every ap- 
proach towards better nutrition, every avoidance of excessive 
fatigue and of other depressing influences undoubtedly tends 
to diminish active infection. Whether to these should be added 
measures directed against the marriage, and especially the inter- 
marriage, of those with a strong family history of phthisis is 
a subject of much greater difficulty. As already indicated 
(p. 189), each family history would, in the event of advice on 
this point being given, need to be considered as a separate 
problem ; and the opportunities for infection in the family, as 
well as the possible inheritance of innate weakness, would need 
to be carefully weighed. 

In this chapter, we propose to endeavour to summarise 
and obtain a conspective view of all those measures against 
tuberculosis which public authorities and the governing bodies 
of hospitals, dispensaries, and friendly societies may be able to 
adopt. Evidently the greatest efficiency of result is likely to be 
secured by first obtaining a complete view of the measures which 
are practicable, and then by bringing the scattered efforts in 
posse as well as in esse into active relationship with each other. 

The following schemes, which to a certain extent overlap, 
show the main official measures and the operations of hospitals 
and dispensaries in the prevention of phthisis. In each scheme 
I have placed the medical officer of health as the agent for 
originating and co-ordinating preventive measures ; and although 



412 THE PREVENTION OF TUBERCULOSIS 




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THE CO-ORDINATION OF MEASURES 



4i3 



personal, domestic, and industrial measures of prevention are 
practicable, and are occasionally practised, apart from notifica- 
tion of cases to the medical officer of health, it is none the less 
true that they are commonly neglected and cannot in the com- 
pletest sense be carried out apart from such notification. 

The second scheme indicates from the point of view of the 
individual patient as well as of the public health what is practi- 
cable under present conditions. 



Patient with 
Phthisis 
notified 

TO THE 

Medical Officer 
of Health. 



SCHEME II 

I. Patient is treated at HOME. 

(1) Under the charge of his own doctor, the dispensary, 
out-patient department of the hospital, etc. 

(2) Home visits are made by the medical officer of health, 
or his assistant, in connection with which 

(a) Cleansing and disinfection are arranged. 
(6) Instructions are given as to general hygiene, 
and as to the special hygiene of the disease. 

(c) Handkerchiefs and spit-bottles are provided as 
required. 

(d) Material aid is given in conjunction with 
voluntary agencies, friendly societies, and 
the poor-law organisation. 

{e) Regular visits to the doctor or dispensary are 
( urged. 

(/) Dispensary or hospital tickets are given to 
other members of the same family who 
appear to be failing in health. 
{g) Free bacteriological examination of sputum 
from these or from any other suspected 
patients is provided. 
II. Patient is admitted to a Sanatorium. 

(1) Disinfection of the patient's home is arranged. 

(2) Aid is organised as required for the patient's family, 
hospital tickets provided for suspected cases, etc. 

III. Patient is admitted to a Hospital for Advanced Cases. 

At present in most districts the only hospital available for 
advanced patients is the workhouse infirmary, which 
is only available for pauper patients. 

The preceding schemes display the imperfections of our 
present official measures and the reforms which are indicated. 
Thus there are insufficient encouragements to early treatment 
of this most curable disease. We have no system of sickness 
insurance of a national character as in Germany, and medical 
aid is not so readily obtainable as to compensate in part for 
the absence of this. Friendly Societies do not completely fill 
the gap here indicated. We have no universal system of com- 
pulsory notification of phthisis, nor, it may be added, is public 
opinion— without which it would be inoperative — completely 
ripe for such a measure. Sanatorium accommodation for early 



414 THE PREVENTION OF TUBERCULOSIS 

cases] among wage-earners is very deficient. There is a still 
more serious deficiency of institutional treatment for advanced 
patients who are not paupers, but who cannot afford to provide 
suitable treatment at home. The arrangements for providing 
suitable occupation, or part-time employment, for patients dis- 
charged from a sanatorium partially cured, need to be organised 
on a larger scale, and the practicability of industrial colonies 
will require to be considered. 

But even under present conditions a study of the two pre- 
ceding schemes indicates how much admirable work — beyond 
what is done in most communities — can be done under present 
conditions by the full employment of official machinery and by 
its co-operation with voluntary agencies. By proceeding on 
the tried lines described in the preceding chapters, by further 
experimental advance from the points of vantage already 
reached, and above all by the earnest and combined efforts of 
voluntary and official workers, there is, in my opinion, no reason 
why, within a relatively short period, tuberculosis should not 
follow the closely allied disease of leprosy towards extinction. 



BIBLIOGRAPHY 

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416 THE PREVENTION OF TUBERCULOSIS 

Bowditch, H. I. (1862). Paper on the Topographical Distribution 
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BIBLIOGRAPHY 417 

Fowler, J. K. (1906). The Therapeutic Value of Sanatorium 
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Hoffman, F. L. (1901). Industrial Insurance and the Prevention 
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27 



418 THE PREVENTION OF TUBERCULOSIS 

Knopf. Pulmonary Tuberculosis : its Modern Prophylaxis, p. 

55- 
Koch, R. Etiology of Tuberculosis, translated by Stanley Boyd, 
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(1901). Address to British Congress on Tuberculosis. Trans. 

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(1906). Nobel Lecture on " How the Fight against Tuberculosis 

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Kossell, H. (1905). A Report on Human and Bovine Tuberculosis. 

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(1903). Prize Essay on the Erection of a Sanatorium 

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(1906). The Economic Value of Sanatoriums. Lancet, Jan. 6, 

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Lecky and Horton (1907). Revealed Tuberculosis in Children 

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Morgan, G. (1899). Remarks on Tuberculous Adenitis. Brit. Med. 

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Mott, Report of Pathologist to London County Council for year ended 

March 1904, p. 1. 
Moxon (1885). Brit. Med. Journ., vol. i. p. 130. 



BIBLIOGRAPHY 419 

Muller, D. (1905). Milk and Dairy Products as Sources of Infection 
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Newman and Swithinbank (1903). Bacteriology of Milk, p. 268. 

Newsholme, A. (1896). On the Study of Hygiene in Elementary 
Schools. Public Health, vol. iii. p. 135. 

(1901). The Influence of Soil on the Prevalence of Pulmonary 

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(1907). The Co-ordination of the Public Medical Services. An 

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(1907). Poverty and Disease as illustrated by the Course of 

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Osler, W. (1901). The Principles and Practice of Medicine, pp. 258, 

338. 
Parker, W. R. (1903). Sanatoria plus Homes for Consumption. 

Mar. 14, 1903. 
Pearson, Karl (1907). A First Study of the Statistics of Pulmonary 

Tuberculosis. Drapers' Company Research Memoirs. 
Philip, R. W. (1906). The Public Health Aspects of the Prevention 

of Consumption. Brit. Med. Journ., Dec. 1, 1906. 
Powell, Douglas. Lecture on the Prevention of Consumption. 

Journ. San. Inst., Aug. 1904, vol. xxv. pt. ii. p. 353. 



420 THE PREVENTION OF TUBERCULOSIS 

Quain's Dictionary of Medicine. Ed. 1894, vol. ii. p. 414. 
Ransome, A. (1890). The Cause and Prevention of Phthisis, p. 50. 

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BIBLIOGRAPHY 421 

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P- 145. 



INDEX OF PLACES 



Aberdeen, 195, 362 

Alnwick, 196 

America, 17, 218, 222, 229, 236, 241, 290 

Axminster, 200 

Belfast, 148, 218, 383 

Belgium, 243, 256 

Berlin, 132, 144, 184, 228, 287 

Birmingham, 223, 274 

Blackburn, 362 

Bradford, 369 

Brighton, 18, 29, 71, 102, 259, 309, 

312, 324, 334, 342, 343, 348, 352, 

361, 395 
Brompton Hospital, 152 
Brussels, 288 
Brynmawr, 197 

Carlisle, 196 
Chelmsford, 196 
Chichester, 199 
Cincinnati, 290 
Copenhagen, 145, 286 
Croydon, 199, 274 

Denmark, 145 
Dover, 199 
Dublin, 148, 213, 283 
Dundee, 195, 361 
Dunfermline, 362 

Edinburgh, 148, 195, 362, 378 
England, throughout 

France, 200, 222, 231, 235, 242 
Frimley, 387 

Germany, 211, 223, 229, 231, 237, 241, 

254, 372, 413 
Glamorgan, 333 
Glasgow, 148, 195, 275 
Gorbersdorf, 384 
Gottenburg, 285 
Greenock, 195 

Holland, 200 



Ireland, 172, 212, 218, 222, 226, 237, 
243, 247, 254, 259, 269, 281 

Kensington, 274, 284 

Leeds, 274 

Leicester, 196 

Leith, 195 

Lille, 2>77 

Liverpool, 30, 144, 148, 331, 369 

London, 147, 148, 246, 269, 277 

Manchester, 49, 98, 100, 144, 148, 193, 

213, 343 
Massachusetts, 171, 195 

Naples, 56 

New York, 17, 24, 228, 290, 343, 345, 

368 
Nordrach, 230, 285, 384 
Norway, 212, 222, 231, 243, 254, 259 

Oldham, 343 

Paisley, 195 

Paris, 50, 106, 228, 235, 253, 289 

Penzance, 197 

Providence, 171, 219 

Prussia, 171, 222, 253, 287 

Salford, 274 

Salisbury, 196 

San Francisco, 290 

Scotland, 171, 195, 222, 227, 229, 236, 

239, 250, 269, 280 
Sheffield, 223, 275, 343, 345 
Stockholm, 285 
Sussex, 201 
Sweden, 285 
Switzerland, 253 

United States. See America 

Ventnor Hospital, 153 
Victoria Park Hopsital, 152 

Zurich, 363 



INDEX OF NAMES OF PERSONS 

(See also under Bibliography) 



Abraham, 75 

Achard, 181 

Acland, 364 

Allbutt, 48, 163, 179, 315 

Annett, 331 

Arlidge, 109, no 

Armstrong, H., 30 

Ash, 362 

Ashby, 31 

Baillie, 36 

Baldwin, 88 

Baumgarten, 61, 79, 96, 183 

Bayle, 36 

Beevor, H„ 53, 102, 168, 230, 232, 258 

Behring, von, 86, 129, 135, 136 

Beninde, 91 

Bennett, H., $7, 45, 46, 48 

Bernheim, 289 

Bertillon, 289 

Bielefeldt, 18, 372 

Biermer, 146 

Biggs, Hermann, 17, 228, 290 

Bodington, ^8$ 

Bowditch, 195 

Brehmer, 150, 384 

Broadbent, 256, 314 

Brouardel, 48, 181 

Buchanan, 195, 202 

Buhl, 37, 79 

Bulstrode, 153, 252 

Burton-Fanning, 177, 188 

Buschke, 81 



Cadeac, 54, 116 
Calmette, 116, 313 
Cameron, C, 283 
Carswell, 48 
Carter, V., 264 
Chantemesse, 81 
Chapin, 219 
Charcot, 48 
Charrin, 177 



377 



Chauveau, 40 

Cheyne, W., 60 

Chopin, 57 

Coates, 23, 49 

Coates, H., 98 

Cohnheim, 40, 60, 109 

Colman, 119 

Cook, C. W., 109 

Cornet, 59, 78, 88, 95, 96, 146, i84 ; 320 

Debove, 79 

De Jong, 135 

Delepine, 53, 98, 117, 143, 144 

Dettweiler, 59, 384 

Devlin, 283 

Dieulafoy, 108 

Donkin, 31 

Dreschfield, 193 

Dudgeon, 81 

Elliott, T., 139 



Fagge, 31 

Falk, 115 

Farr, 20 

Fischer, 53, 54 

Fleming, 273 

Flint, 49 

Flugge, 91, 92, 95 

Fowler, J. K., 78, 162, 183, 387 

Fox, Wilson, 60, 152, 185 

Fox, Wilson, C.B., 241 

Frebelius, 164 

Galen, 35 
Ganghofner, 80 
Garland, 375 
Greenhow, no 
Greenwood, 362 
Gresswell, 74 
Griffith, A. S., 124 
Guerin, 116 
Guthrie, 113, 118 



424 



INDEX OF NAMES OF PERSONS 



425 



Harris, T., 4S 
Harvey, G., 56 
Hay, 362 
Hayward, 14 
Hervieux, 164 
Heuss, 135 
Hewlett, no 
Heymann, 92 
Hildebrandt, no 
Hippocrates, 35, 48 
Hirsch, 194, 201, 202 
Hoff, 286 
Hoffman, 17, 374 
Horton, 361 

Kanthack, 53, 144 

Kelly, 201 

Kelynack, 383 

Kingsford, 120 

Kitasato, 78, 103 

Klebs, 60 

Klemperer, 129 

Klencke, 38 

Knauff, no 

Knopf, 368 

Koch, R., 41, 52, 59, 60, 89, I2i, 12} 

131, 146, 154, 252 
Kossel, 125, 132, 135, 136 

Laennec, 36, 49 
Landouzy, 23, 181 
Lartigau, 54, 88, 131 
Laschtschenko, 92 
Latham, 109, 120, 385 
Lebert, 37 
Lecky, 71, 361, 397 
Lister (Lord), 1 1 1 
Lister, T. D., 24, 375 
Loomis, 79 
Lorenz, 136 
Louis, 49 
Low, 362 
Lyon, G., 24 

MacConkey, 79 

MacCormac, H., 383 

MacFadyean, J., 139, 142, 182, 313 

Macfadyen, A., 79 

Mackenzie, L., 362 

M'Weeney, 144 

Magnetus, 36 

Marfan, 81 

Martin, H., 46 



Martin, S., 61, 108, 116, 126, 140 

Matheson, 148, 227 

Mesurier, 289 

Metchnikoff, 44 

Milroy, 195 

Moller, 135 

Morgagni, 36, 55 

Morgan, 108 

Mott, 178, 274 

Moxon, 53 

Muirhead, 374 

Miiller, 80, 116, 143 

Murphy, S., 147 

Naegeh, 363 

Newman, 162, 355 

Niemeyer, 37 

Niven, 319, 343, 355, 370 

Nocard, 135 

Nuttall, 104 

Ostertag, 143 

Paget, 343 
Parker, 302 
Pasteur, 41, 75 
Pearse, 200 
Pearson, K., 187 
Philip, 378, 381, 382 
Powell, 230 

Rabinowitch, 144 

Ransome, 54, 89, 180, 193 

Ravenel, 125, 130, 131, 132, 135 

Reid, 36 

Reinhardt, 37 

Ribard, 48 

Richardson, 383 

Rindfleisch, 111 

Robertson, 153, 165, 345 

Rokitansky, 37 

Romer, 136 

Russell, H. W., 118 

Sand, George, 57 
Sanderson, B., 39 
Santoliquido, 255 
Savoire, 377 
Schultze, in 
Schiitz, 125, 128 
See, 162 

Shadwell, 222, 228, 241 
Simon, J., 40 



426 



THE PREVENTION OF TUBERCULOSIS 



Smith, Theobald, 124, 121, 134, 409 

Smollett, 56 

Spengler, 129 

Spillmann, 88 

Squire, 109, 113, 185, 313, 390 

Stafford, 180 

Stead, 375 

Stengel, 77 

Sternberg, 409 

Still, 119 

Strauss, 53, 106, 115 

Swithinbank, 162 

Sylvius, 35 

Tappeiner, 41, 96 

Tatham, 3, 7, 155, 158, 165, 172, 213, 

360 
Taute, 135 

Thomson, St. Clair, 106, 108, no, 112 
Thorne, 32, 201 
Trudeau, 192, 382 
Turban, 315 
Tyndall, 89, 105 

Vagades, 131 



Valsalva, 55 
Villemin, 38, 41, 59, 89 
Villoret, in 
Virchow, 37 
Volland, 114 

Walker, 393 

Walsham, H., 113 

Walshe, 59, 185 

Walters, F. R., 384, 387, 393 

Walther, 384 

Washbourne, 79, 81 

Watson, 15 

Weber, 135, 150 

West, 185 

Wesener, 115 

Williams, C. T., 49, 89, 152, 184, 314 

Williams, D., 60 

Wright, 31 

Wright, A., 44 

Woodhead, Sims, 109, 113, 142, 144 

Zenker, no 
Ziemssen, 390 
Ziehl-Nielsen, 60 



INDEX OF SUBJECTS 



Adenoids, 108, 302 

Advanced cases, treatment of, 366, 401 
After-care of patients, 392 
Age-incidence of tuberculosis, 6, 29, 

118, 164, 219 
Agricultural labourers' wages, 241 
Air, expired, and infection, 88 
Alcohol and phthisis, 181, 304, 319 
Asylums and phthisis, 178, 274 
Attendance on sick and infection, 

152 
Auto-infection, 310 

Bacillus tuberculosis, 5 1 

number in expectoration, 104 
bovine and human, 124, 134 

Bovine tuberculosis, 121 

Bronchial glands and infection, 112 

Bronchitis, confusion with phthisis, 24 
relation to phthisis, 1 79 

Bye-laws as to spitting, 334 

Catarrhs and phthisis, 178 
Cattle and tuberculosis, 139 
Children, latent tuberculosis in, 80, 363 
Cleanliness, 302 
Climate and phthisis, 194 
" Colds " and phthisis, 178 
Common lodging-houses, 368 
Comparative mortality figures, 157 
Compulsory notification, 344, 349 

removal of patients, 367 
Congenital phthisis, 182 
Co-ordination of measures, 41 1 
Correlation coefficients, 295 
Coughing and infection, 97 
Cows' milk. See Milk 

Dairy products and tuberculosis, 145 
Death-rate. See Mortality 
Decadence, 217 
Definition of tuberculosis, 3 
Desiccation and life of bacillus, 52 



Diagnosis, accuracy of, 23 
importance of early, 306 
Diseases predisposing to phthisis, 178 
Disinfection, 321, 327, 355 
Dispensaries and prevention of phthisis, 

377 
Doctors and infection, 155 

and preventive measures, 316 

and disinfection, 321 

and notification, 321 
Domestic infection, 146 
Drainage of soil, 196 
Droplets, infection by, 93 
Duration of life and phthisis, 14 
Dust infection, 91, 97, 105, 120 

in rooms, infectivity of, 94 
Dwelling and infection, 104, 146, 225, 
304 

Economics of tuberculosis, 13, 17 
Education and phthisis, 252, 302 

of patient, 357 

authorities and phthisis, 359 
Elimination of susceptible strains, 

216 
Emigration and phthisis, 218 
Entry of infection, 108 
Environmental conditions, 

lowering resistance, 191, 215 
Expectoration in phthisis, 102 

and tubercle bacilli, 103, 314 

swallowing of, 320 

prevention of, 331 

disposal of, 332 

regulations as to, 333 
Experimental investigation, 38 

evidence as to infection, 89, no 
Expired air and infection, 89, 105 
Extra-corporeal life of bacillus, 104 

Family infection, 149 
Fatigue, 177, 303 
Financial loss by phthisis, 15 
427 



428 



THE PREVENTION OF TUBERCULOSIS 



Flies and infection, 88 
Food cost and phthisis, 236 

amount and phthisis, 243 

and tuberculosis, 403 
Friendly Societies' experience, 1 5 

and phthisis, 374 

Gastric juice, 115 
General tuberculosis, 27, ^7> 114 
German insurance scheme, 1 8 
Guardians, Boards of, and phthisis, 
3,66 
and sanatoria, 369 

Hands and infection, 87 
Heredity and phthisis, 182 
History of phthisis, 35 

views on infection, 55 

importance in diagnosis, 312 
Home treatment, 326 

of pauper cases, 370 
Hospitals and dust infection, 98 

and infection, 153 
House. See Dwelling 
Housing, 104, 146, 225, 304 
Hygiene, teaching of, 302 

Ignorance, removal of, 311 
Income of family and phthisis, 241 
Incubation period, 75 
Industrial infection, 157 

prevention, 329 

colonies, 393 
Infection, history of views on, 5 5 

experimental evidence of, 59 

channels of, 60 

statistical and clinical evidence, 62 

sources of, 86 

limitations to, 10 1 

by inhalation, 106 
Infirmaries and phthisis, 18, 246, 273 
Influenza and phthisis, 178 
Ingestion of infection, 115 
Inhalation of infection, 106 
Injury and phthisis, 178 
Inoculation of tuberculosis, 87 
Institutional treatment of advanced 

cases, 366 
Instructions for patients, 324 
Insurance Societies' experience, 17 

and phthisis, 372 
Intestinal infection, 116 
Isolation hospitals and phthisis, 397 



Latency, duration of, 73, 257 
pathological evidence as to, 77 
in scholars, 363 

Latent tuberculosis, treatment of, 363 

Leprosy and phthisis in Norway, 259, 
263 

Limitations to infection, 101, 105 

Living, cost of, 238 

Lunatic asylums. See Asylums 

Lungs, direct infection of, 109 
indirect infection of, 112 

Magnitude of the evil, 4 
Malnutrition, 179, 303 
Married life and infection, 149 
Meat and tuberculosis, 139, 404 
Medical treatment, 306 

service, 310 
Milk and tuberculosis, 130, 141, 144, 

406 
Mortality from tuberculosis, 4 

according to age, 4 

according to sex, 7 

Notification of phthisis, 338 

and decline of phthisis, 253, 301 
and doctors, 321 
Nursing and infection, 
Nutrition and phthisis, 179, 230 

Occupation and phthisis, 158 

of consumptives, 327 
Open-air treatment, history of, 383 
Ophthalmic diagnosis, 313 
Overcrowding and phthisis, 147, 191, 

224, 229 
Overfatigue and phthisis, 1 yy 

" Parochial " statistics, 207 
Pauperism and phthisis, 243 
Phagocytosis in phthisis, 44 
Phthisis. See Tuberculosis 

confusion with tuberculosis, 26 

symptoms and progress of, 43 

varieties of, 47 

curability of, 48 

duration of, 49 
Precautionary instructions, 324 
Prevention and cure inseparable, 325 
Portals of infection, 106 
Poverty and phthisis, 179, 219, 243, 

304 
Prae-tuberculous stage, 312 



INDEX OF SUBJECTS 



429 



Predisposition, 162 

diseases producing, 178 
hereditary, 184, 216 

Proclivity, 161 

Proteid food and phthisis, 231 

Public-house and infection, 181 
319 



304, 



Railway carriages and infection, 100 
Regulations as to spitting, 333 
Relief for consumptive families, 370 
Royal Commissions on Tuberculosis, 

I2i, 126, 132 
Rural life and phthisis, 220 

Saliva and infection, 88 

Sanatoria and decline of phthisis, 254 

and Boards of Guardians, 369 

structural arrangements of, 384 
Sanatorium treatment, principles of, 
386 

medical results of, 390 

patients suitable for, 391 

and doctors, 322 

and prevention of phthisis, 382 
Sanitary Authority and patient, 328 

and preventive measures, 351 
Sanitary measures and phthisis, 192, 

211, 215, 356 
Scholars, latent tuberculosis in, 363 
School-ages and phthisis, 360 
Schools and spread of tuberculosis, 362 

and public opinion, 365 
Secret medical, le, 340 
Segregation and phthisis, 149, 256, 266 

domestic and institutional, 258 

ratio, 267 
Sex and tuberculosis, 164, 226 

and urban or rural phthisis, 165 

differences between boys and girls, 
168 

changes in incidence according to, 
171 
Sickness, amount of, from tuberculosis, 

13 
relation of, to mortality, 20 
Soil and phthisis, 194 
Speaking and infection, 95 
Spitting. See Expectoration 
Spray infection, 92, 120 



Sputum, examination of, 102, 314 

swallowing of, 320 

disposal of, 332 
Statistics, trustworthiness of, 22 

" parochial," 207 

migration and, 208 
Streets and tubercle bacilli, 104, 331 

and expectoration, 336 
Subsoil drainage, 196 
Sunlight and infection, 53, 193 
Susceptibility, 161, 216. See also Pre- 
disposition 

Tabes mesenterica, 23, 31, 118 
Teeth and infection, 109 
Temperance and phthisis, 210 
Temperature and life of bacillus, 53, 409 
Thrift and phthisis, 210, 231 
Tonsils and infection, 109 
Training of patients, 391, 395 
Transformation of types of bacilli, 134 
Treatment, need for organisation of, 306 
Tubercle, nature of, 45 
Tubercle bacillus. See under Bacillus 
Tuberculin testing, 313 
Tuberculosis. See also under Mortality 
Tuberculous meningitis, 29, 118 

peritonitis, 31 
Typhus fever and phthisis in Ireland, 

259, 262 
Typus humanus, 124, 134 

bovinus, 124, 134 

Ubiquity of tubercle bacillus, 101, 104, 

33i 
Udder disease and tuberculosis, 143 
Urban life and phthisis, 220, 223 

Virulence of tubercle bacillus, 215 
Visits to consumptives, 359 
Voluntary notification, growth of, 342 

Wages and phthisis, 240 
Weight, loss of, 313 
Well-being and phthisis, 230 
Wheat prices and phthisis, 232 
Wife contrasted with nurse as to infec- 
tion, 154 
Workers, sanatoria for, 375 
Workhouse. See Infirmaries 



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